Jeffrey B. Halter • Joseph G. Ouslander • Stephanie Studenski Kevin P. High • Sanjay Asthana • Mark A. Supiano Christine S. Ritchie • Kenneth Schmader

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Deportment of Internal Medicine DivisionofGeriatric and PalliativeMedkine University of Michigan

Yong Loo Lin School of Medicine National University of Singapore Ann Arbor, Michigan

President, Atrium Health— Wake Forest Baptist Professor of Internal Medicine-Infectious Diseases Wake Forest School of Medicine

Duncan G ami LottieII, BalLintine Endowed Chair in Geriatrics University of Wisconsin School of Medicine and Public Health Madison Wisconsin

Kenneth L. Minaker Endowed Chair in Geriatric Medicine Director.Mongan Institute Center for Aging and Serious Illness

I. Paul Sticht Center on Agingand Rehabilitation Wake Forest School of Medicine Winston‘Salem,North Carolina

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SECTION A: Assessment

SECTION A: Cardiovascular System

Numbers in brackets refer to the chapters written or cowritten by the contributor.

Owoicho Adogwa, MD, MPH Associate Professor of Neurosurgery Department of Neurological Surgery

Section of Pulmonary, Critical Care and Sleep Medicine Yale University School of Medicine

Director, Medical Intensive Care Unit VA Connecticut Healthcare System West Haven, Connecticut [81]

Department of Behavioral and Community Health Sciences Graduate School of Public Health

Director, Geriatric Research, Education and Clinical Center; VA Greater Los Angeles Healthcare System

Professor, Department of Medicine University of California, Los Angeles Los Angeles, California [44]

Duke University and Duke Clinical Research Institute Durham, North Carolina [74]

Chief of Medicine, University of Washington Medical Center Seattle, Washington [97]

Division of Infectious Diseases, Department of Internal Medicine University of Nebraska Medical Center

Professor and Head, Division of Geriatrics and Gerontology Director, NIA/NIH Wisconsin Alzheimer Disease

Director, Madison VAMC Geriatric Research, Education and Clinical Center (GRECC)

Duncan G. and Lottie H. Ballantine Endowed Chair in Geriatrics University of Wisconsin School of Medicine and Public Health Madison, Wisconsin [59]

Thilinie D. Bandaranayake, MBBS Assistant Professor of Medicine Section of Infectious Diseases

Madison VA Geriatric Research, Education and Clinical Center Professor of Medicine, Geriatrics/Sleep Medicine

University of Wisconsin-Madison School of Medicine and Public Health Madison, Wisconsin [31]

Department of Geriatric Medicine John A. Burns School of Medicine University of Hawaii

Departments of Anesthesiology and Perioperative Medicine and Neurology University of Pittsburgh School of Medicine

Behavioral Neurology Clinical Fellow Weill Institute for Neurosciences Memory and Aging Center

Marcus Stroke and Neuroscience Center at Grady Memorial Hospital and Emory University School of Medicine

Program Director, Geriatric Medicine Fellowship Program Washington University in St. Louis, School of Medicine

Adjunct Professor Geriatric Medicine and Palliative Care NYU Grossman School of Medicine

Professor of Radiology (Division of Nuclear Medicine) and Neurology University of Michigan

Professor of Medicine, Epidemiology and Health Policy and Management Division of Geriatric Medicine and Gerontology

Center for Transformative Geriatric Research Johns Hopkins University School of Medicine Baltimore, Maryland [41]

Associate Dean for Faculty Affairs and Development, School of Health and Rehabilitation Sciences

Associate Professor, Department of Anesthesiology Wake Forest University School of Medicine Winston Salem, North Carolina [68]

Division of General Internal Medicine Section Chief Geriatric Medicine University of New Mexico Albuquerque, New Mexico [83]

Assistant Professor, Director of UCSF Aging Skin and Geriatric Dermatology Clinic

Division of Geriatrics, Gerontology, and Palliative Medicine, Department of Internal Medicine

Division of Palliative Medicine and Geriatrics The Massachusetts General Hospital

Division of Endocrinology, Diabetes, and Metabolism Director, Penn Medical Communication Research Institute Perelman School of Medicine at the University of Pennsylvania Philadelphia, Pennsylvania [98]

University of Wisconsin School of Medicine and Public Health Madison, Wisconsin [59]

Christopher R. Carpenter, MD, MSc Professor of Emergency Medicine Department of Emergency Medicine

Associate Director, Education and Evaluation Geriatrics Research Education and Clinical Center William S. Middleton Memorial VA Medical Center Madison, Wisconsin

Department of Medicine – Division of Geriatrics and Gerontology University of Wisconsin School of Medicine and Public Health Madison, Wisconsin [18]

University of Wisconsin School of Medicine and Public Health Madison, Wisconsin [59]

Geriatrician and Conjoint Professor Prince of Wales Clinical School University of New South Wales Sydney, Australia [13]

Director Emeritus, Center for the Study of Aging and Human Development Chair Emeritus, Department of Medicine

Division of Geriatric Medicine & Gerontology Johns Hopkins University School of Medicine Baltimore, Maryland [17]

Co-Director, Sticht Center on Healthy Aging and Alzheimer’s Prevention Wake Forest School of Medicine

Department of Internal Medicine, Division of Palliative Medicine Washington University in St. Louis School of Medicine

Professor, Division of Geriatric Medicine & Palliative Care Program Medical Director, UNC Home Hospice & Hospice Home

Section of General Internal Medicine – Geriatrics Dartmouth-Hitchcock Medical Center

Geriatrician, Chair of Medicine and Director of the Australian Institute for Musculoskeletal Science (AIMSS)

Veterans Affairs Birmingham/Atlanta Geriatric Research Education and Clinical Center (GRECC)

Department of Medicine, Geriatrics and Gerontology Emory University School of Medicine

Divisions of Infectious Diseases and Geriatric Medicine University of Colorado—Anschutz Medical Campus Aurora, Colorado [107]

Barshop Institute for Longevity and Aging Studies University of Texas Health Science Center at San Antonio

Director, Geriatrics Research, Education and Clinical Center South Texas Veterans Health Care System

Geriatrics Division Associate Chief for Age-Friendly Care Spencer Fox Eccles School of Medicine at the University of Utah

Physician Investigator, VA Salt Lake City Geriatric Research, Education, and Clinical Center

Geriatrician, Department of Geriatric Medicine, Western Health Australian Institute for Musculoskeletal Science (AIMSS)

Cynthia Felix, MD, PhD Postdoctoral Associate Department of Epidemiology University of Pittsburgh Pittsburgh, Pennsylvania [4]

Associate Professor of Neurology, Harvard Medical School Staff Neurologist, Beth Israel Deaconess Medical Center

Assistant Scientist, Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife

Azienda ULSS 7 Pedemontana - Alto Vicentino Hospital Via Garziere, Santorso (Vicenza), Italy [85]

Department of Internal Medicine University of California Los Angeles Los Angeles, California [35]

SUNY Upstate Medical University and Hematology-Oncology Associates of Central New York

Director, Comprehensive Center for Brain Health University of Miami Miller School of Medicine Miami, Florida [9]

Department of Medicine, Division of Geriatric Medicine University of Colorado Anschutz Medical Campus Aurora, Colorado [54]

Deputy Director, Center for Health Disparities Research Associate Professor, School of Nursing

Director, Heart Failure with Preserved Ejection Fraction and Cardiac Amyloidosis Program

Department of Anesthesiology Wake Forest School of Medicine Winston Salem, North Carolina [28]

Matthew E. Growdon, MD, MPH Geriatrician and Aging Research Fellow Division of Geriatrics

Division of Pulmonary and Critical Care Duke University Medical Center Durham, North Carolina [80]

Professor of Medicine, Family Medicine and Community Health, and Population & Quantitative Health Sciences

Yong Loo Lin School of Medicine National University of Singapore Ann Arbor, Michigan [99]

Division of Geriatrics, Gerontology, and Palliative Care University of California, San Diego

Gerontology and Geriatric Medicine Atrium Health Wake Forest Baptist Winston-Salem, North Carolina [108]

Division of Geriatric Medicine & Gerontology Johns Hopkins University School of Medicine Baltimore, Maryland [17]

Professor of Internal Medicine–Infectious Diseases Wake Forest School of Medicine

Division of Geriatrics, Department of Medicine University of Colorado Anschutz Medical Campus Aurora, Colorado [54]

Director, Heart Failure with Preserved Ejection Fraction Program University of Michigan

Professor, Vice Chair for Research Department of Emergency Medicine Yale School of Medicine

Geriatric Research, Education and Clinical Center James J. Peters VA Medical Center

Marcus Institute for Aging Research, Hebrew SeniorLife Milton & Shirley F. Levy Family Chair

Staff Physician, Beth Israel Deaconess Medical Center Boston, Massachusetts [58]

Director of Inpatient Adult Palliative Care Consultation Department of Psychosocial Oncology and Palliative Care Dana-Farber Cancer Institute/Brigham and Women’s Hospital Instructor of Medicine, Harvard Medical School

Senior Associate Dean for Healthy Aging and Senior Care Estelle and Edgar Levi Chair in Aging

Distinguished Professor of Psychiatry and Neurosciences Director, Sam and Rose Stein Institute for Research on Aging Department of Psychiatry, University of California, San Diego San Diego, California [66]

Medical Director, VA Surgery Quality Improvement Program University of Nebraska Medical Center

Associate Professor of Geriatrics, and Family and Preventive Medicine University of Arkansas for Medical Sciences

Theodore M. Johnson, II, MD, MPH, AGS-Fellow Paul Seavey Chair and Chief, General Internal Medicine Chair, Family and Preventive Medicine

Section on Gerontology & Geriatrics, Sticht Center on Healthy Aging and Alzheimer’s Prevention

Chief, Palliative Medicine, Palliative Care Program Section of Palliative Medicine

Florida State University, College of Medicine and College of Law Tallahassee, Florida [26]

School of Social Work and Department of Developmental Psychology University of Michigan

Dae Hyun Kim, MD, MPH, ScD Associate Professor of Medicine Harvard Medical School

Associate Dean for Social Health Sciences and Programs Director, UW Center for Health Disparities Research Professor, Department of Medicine

University of Wisconsin School of Medicine and Public Health Madison, Wisconsin [6] [18]

Boston University School of Medicine Jamaica Plain VA Medical Center Boston, Massachusetts [64]

Sections on Cardiovascular Medicine and Geriatrics/Gerontology Wake Forest School of Medicine

Section on Hematology and Oncology Wake Forest School of Medicine Winston-Salem, North Carolina [95]

Mayo Clinic College of Medicine Department of Cardiovascular Diseases Mayo Clinic Arizona

Professor and Travelers Chair in Geriatrics and Gerontology Director, UConn Center on Aging

Department of Internal Medicine Division of General Medicine University of Michigan

Division of Rheumatology, Department of Medicine, and University of Arizona Arthritis Center

Assistant Professor of Psychiatry University of California, San Diego Staff Psychiatrist

Jiha Lee, MD, MHS Assistant Professor University of Michigan Ann Arbor, Michigan [101]

Professor of Medicine, Cell Biology & Pathology Division of Pulmonary, Allergy and Critical Care Duke University School of Medicine

Geriatric Research Education and Clinical Center (GRECC) VA Ann Arbor Healthcare System

Division of Geriatric Medicine & Gerontology Johns Hopkins University School of Medicine Baltimore, Maryland [17]

Marcus Stroke and Neuroscience Center at Grady Memorial Hospital and Emory University School of Medicine

Departments of Obstetrics and Gynecology and Medicine-Geriatrics and Palliative Medicine

Chief Academic Officer and Director, Marcus Institute for Aging Research, Hebrew Senior Life

Chief, Division of Gerontology, Beth Israel Deaconess Medical Center Editor-in-Chief, Journal of Gerontology Medical Sciences

Julia Loewenthal, MD Instructor in Medicine Harvard Medical School Division of Aging

David B. Lombard, MD, PhD Associate Professor Department of Pathology University of Michigan

Falls Balance and Injury Research Centre Neuroscience Research Australia University of New South Wales

Chief, Division of Gastroenterology and Hepatology Co-Medical Director, UW Digestive Health Center Medical Director, UW Liver Transplant Program

University of Wisconsin School of Medicine and Public Health Madison, Wisconsin [86]

Elizabeth Plank Althouse Professor, Johns Hopkins University Director, Richman Family Precision Medicine Center of Excellence in

Director, Johns Hopkins Memory and Alzheimer’s Treatment Center Baltimore, Maryland [60]

Researcher, Montreal Heart Institute Research Center Assistant Professor, Faculty of Nursing

Department of Internal Medicine, Division of Rheumatic Diseases UT Southwestern Medical Center

Preeti N. Malani, MD, MSJ Chief Health Officer Professor of Medicine University of Michigan

Medical Director, Aurora Senior Services & Aurora at Home Geriatrics Fellowship Director, Aurora Sinai Medical Center Clinical Adjunct Professor of Medicine

University of Wisconsin School of Medicine & Public Health Co-Editor, Journal of Geriatric Emergency Medicine (JGEM)

Section Editor, Journal of the American Geriatrics Society (JAGS) Models of Geriatric Care, Quality Improvement and Program Dissemination Milwaukee, Wisconsin [14]

Emeritus Geriatrician and Professor of Medical Gerontology Population Health Sciences, Faculty of Life Sciences and Medicine King’s College London

President and Chief Executive Officer Institute for Healthcare Improvement Boston, Massachusetts

Director, Colorado Program for Patient Centered Decisions Associate Professor of Medicine

Professor Emeritus, Department of Medicine Division of Gerontology and Geriatric Medicine University of Washington School of Medicine

Clinical Investigator, Geriatric Research, Education and Clinical Center VA Puget Sound Health Care System

Director, Clinical Cardiovascular Research Laboratory for the Elderly Columbia University Irving Medical Center

Assistant Professor of Medicine, Harvard Medical School Senior Physician, Dana-Farber Cancer Institute

Director of the BU Chronic Traumatic Encephalopathy (CTE) Center Boston University School of Medicine

Darshan H. Mehta, MD, MPH Assistant Professor of Medicine Harvard Medical School Education Director

Brigham and Women’s Hospital and Harvard Medical School Boston, Massachusetts [24]

Falls Balance and Injury Research Centre Neuroscience Research Australia University of New South Wales

Department of Health Services, Policy, and Practice Brown University School of Public Health Providence, Rhode Island [19]

University of California San Francisco School of Nursing San Francisco, California [69]

A.W. and Mary Margaret Clausen Distinguished Professor of Neurology Director, Memory and Aging Center

Chief, Division of Geriatrics, Gerontology, and Palliative Care University of California, San Diego

Department of Medicine, Division of Geriatrics University of Colorado Anschutz Medical Campus Aurora, Colorado [54]

Mary Jones Hudson Distinguished Professor of Geriatric Oncology Professor of Medicine

Director of Geriatric Oncology, Lineberger Comprehensive Cancer Center University of North Carolina

Professor and Nancy P. & Vincent F. Guinee, MD Distinguished Chair Department of Management, Policy and Community Health, University of

Executive Director, UTHealth Institute on Aging University of Texas Health Science Center Houston, Texas

Investigator, Houston Center for Innovations in Quality, Effectiveness and Safety

Abhijit S. Naik, MD, MPH, FASN Assistant Professor of Internal Medicine Division of Nephrology

Department of Epidemiology, Graduate School of Public Health University of Pittsburgh

Medical Oncology at Stephenson Cancer Center University of Oklahoma Health Sciences Center Oklahoma City, Oklahoma [92]

Assistant Professor of Medicine and Health Policy and Management Division of Geriatric Medicine and Gerontology

Center for Transformative Geriatric Research Johns Hopkins University School of Medicine Baltimore, Maryland [41]

Michele R. Obert, MD Internal Medicine Resident Department of Medicine University of Arizona Tucson, Arizona [52]

Beth Israel Dermatology, Beth Israel Deaconess Medical Center Associate Professor of Dermatology

Senior Advisor to the Dean for Geriatrics Charles E. Schmidt College of Medicine

Professor (Courtesy), Christine E. Lynn College of Nursing Florida Atlantic University

Ambarish Pandey, MD, MSCS Assistant Professor of Internal Medicine Division of Cardiology

University of California, Berkeley School of Social Welfare Berkeley, California [20]

Chair, Division of Geriatric Medicine & Gerontology Robert and Arlene Kogod Professor of Geriatric Medicine Mayo Clinic College of Medicine

Director Department Geriatric Care, OrthoGeriatrics and Rehabilitation Galliera Hospital

Section of Pulmonary, Critical Care and Sleep Medicine Yale University School of Medicine

Medical Director, Winchester Center for Lung Disease and Director, Post- COVID Recovery Program

Professor, Department of Medicine Section on Hematology and Oncology Wake Forest School of Medicine Winston-Salem, North Carolina [95]

Fellow, Division of Urogynecology and Pelvic Reconstructive Surgery Instructor, Department of Obstetrics and Gynecology

Scientist, UW Center for Health Disparities Research (CHDR) University of Wisconsin School of Medicine and Public Health Madison, Wisconsin [6]

Assistant Professor, Associate Medical Director Oncogeriatrics Program Division of Medical Oncology, Department of Internal Medicine

University of Wisconsin School of Medicine and Public Health Geriatric Research, Education and Clinical Center (GRECC) William S. Middleton Memorial Veterans Hospital

Archstone Professor of Medicine/Geriatrics David Geffen School of Medicine at UCLA Los Angeles, California [8]

Professor of Obstetrics and Gynecology, Urology and Geriatrics Research Director, Division of Urogynecology and Pelvic Reconstructive

Associate Director, Gynecologic Research, Center for Women’s Reproductive Health

Medical and Quality Officer, Ambulatory OBGYN Clinics University of Alabama at Birmingham

Kenneth L. Minaker Endowed Chair in Geriatric Medicine Director, Mongan Institute Center for Aging and Serious Illness Professor of Medicine

University of Wisconsin-Madison School of Medicine and Public Health Madison, Wisconsin [31]

Clinical Instructor in Medicine, Harvard Medical School Director, GME Diversity Inclusion and Advocacy

Director, Diversity Recruitment & Retention, BIDMC Internal Medicine Residency Program

National Institute of Geriatric Medicine at the National Institutes of Health Mexico

Section of Pulmonary, Critical Care and Sleep Medicine Yale University School of Medicine

Professor, Department of Medicine, Division of Geriatric Medicine and Dalla Lana School of Public Health

Division of Geriatrics and Gerontology, Department of Medicine University of Wisconsin-Madison School of Medicine and Public Health Director of Swallowing and Salivary Bioscience Lab

Geriatric Research Education and Clinical Center (GRECC) William S. Middleton Memorial Veterans Hospital Madison, Wisconsin [31]

Program Director, Vulnerable Elder Protection Team (VEPT) Weill Cornell Medicine / New York-Presbyterian Hospital New York, New York [48]

University of Texas Health Sciences Center at San Antonio Medical Director for GEC Transitions of Care

Division of Palliative Care and Geriatric Medicine Massachusetts General Hospital/Harvard Medical school Boston, Massachusetts [71]

Division of Pulmonary, Critical Care, and Sleep Medicine Veterans Affairs Greater Los Angeles Healthcare System University of California Los Angeles

Francisco Javier Martín Sánchez, MD, PhD Associate Professor of Medicine Complutense University

Professor of Biological Chemistry in Otolaryngology Department of Otolaryngology - Head & Neck Surgery University of Michigan Medical School

Kenneth Schmader, MD Professor of Medicine-Geriatrics Duke University Medical Center

Director, Geriatric Research Education and Clinical Center (GRECC) Durham VA Health Care System

Department of Otolaryngology - Head & Neck Surgery Medical University of South Carolina

Department of Pathology and Laboratory Medicine Medical University of South Carolina

Physiatrist/Associate Research Physician Rehabilitation Medicine Department National Institutes of Health

Albert C. Shaw, MD, PhD Professor of Medicine Section of Infectious Diseases Yale School of Medicine

Board-certified Clinical Specialist in Geriatric Physical Therapy University of Pittsburgh

Manager, Signature Initiatives and Partnerships Institute for Healthcare Policy and Innovation University of Michigan

Geriatric Dermatology Research and Clinical Student Fellow Department of Dermatology

Sinai Health System and the University Health Network Hospitals Departments of Medicine and Health Policy, Management and Evaluation Women’s College Research Institute

University of Wisconsin School of Medicine and Public Health Madison, Wisconsin [86]

Division of Urogynecology and Pelvic Reconstructive Surgery Department of Obstetrics and Gynecology

Director, Geriatric Research Education and Clinical Center VISN 16/Central Arkansas Veterans Healthcare System

Executive Director, University of Utah Center on Aging Salt Lake City, Utah [79]

Division of Endocrinology, Metabolism and Diabetes University of Colorado Anschutz Medical Campus Aurora, Colorado [54]

Departments of Medicine and Health Policy Vanderbilt University Medical Center Nashville, Tennessee [108]

Associate Chief of Staff, Geriatrics, Palliative, & Extended Care Service George E. Wahlen Veterans Affairs Medical Center

Associate Clinical Professor of Medicine Department of Internal Medicine Washington University School of Medicine St. Louis, Missouri [67]

Medical Director, Acute Care for Elders (ACE) Program and AGS CoCare: Hospital Elder Life Program (HELP)

University of Wisconsin School of Medicine and Public Health Milwaukee, Wisconsin [14]

Clinical Professor of Medicine/Geriatrics (Affiliated) Stanford University School of Medicine, Stanford, CA GRECC (182B)

Professor and Chief, Division of Geriatrics and Palliative Medicine Physician-Investigator, Veterans Affairs Western New York Healthcare

Director, Center of Excellence for Alzheimer’s Disease Jacobs School of Medicine and Biomedical Sciences University at Buffalo

Associate Professor of Internal Medicine Section on Cardiovascular Medicine Wake Forest School of Medicine Winston-Salem, North Carolina [73]

Department of Neurology and Division of Geriatric Medicine University of California San Francisco

Division of Geriatrics & Gerontology, Department of Medicine Emory University School of Medicine

University of Michigan & VA Ann Arbor Healthcare System Ann Arbor, Michigan [72]

Raymond and Anna Lublin Professor of Geriatric Medicine Johns Hopkins University School of Medicine

Director, National Blind Rehabilitation Service (Retired) Department of Veterans Affairs

Brigham and Women’s Hospital and Harvard Medical School Boston, Massachusetts [24]

Professor of Medicine, Psychiatry, Anesthesiology and Clinical & Translational Science

Director, Hospice and Palliative Care, San Francisco VA San Francisco, California [67]

Associate Professor of Medicine Division of Oncology, Section of Medical Oncology

Director of Clinical Research, Osher Center for Integrative Medicine Department of Medicine

Rehabilitation Medicine Department National Institutes of Health Bethesda, Maryland [103]

Jeffrey B. Halter M.D. Collegiate Professor of Geriatric Medicine Director, Geriatrics Center and Institute of Gerontology

Geriatrician, Research Fellow, Australian Institute for Musculoskeletal Science (AIMSS)

“My inspiration and my passion will always come from my older patients. One day I hope to be like them; when that day comes, I hope that my doctor will be a geriatrician.”1

It has been my privilege as Editor Emeritus of this latest edition to follow its progress over the past 2 years from design at the first meeting of the editorial board in September 2019 to publication. I am pleased to predict that the eighth edition of Hazzard’s Geriatric Medicine and Gerontology will solidify its reputation as the leading “go to” source for readers seeking the latest, most comprehensive, in-depth, and reliable treatise in research and practice that optimizes the care of our aging and older patients. Moreover, this edition will continue to expand its influence toward worldwide enhancement in the care of those patients, whose numbers are expanding dramatically as population aging becomes a global phenomenon.

Especially gratifying in my association with this textbook has been its widespread use as core material in geriatric fellowship training programs. I am frequently flattered to be asked to autograph the latest volume for fellows who have come to value the book highly during their training for its accessibility, breadth, depth, and authenticity as a single source for their scholarly education in our field.

Their appreciation brings me special satisfaction. A focused approach on geriatrics fellows in training as our primary target audience was adopted by Reubin Andres, Ed Bierman, and me when, in 1983, we were charged by McGraw Hill to collaborate as editors of the first edition of a new textbook in the field, Principles of Geriatric Medicine. We envisioned our textbook as complementing the prior education that physicians received in medical school, graduate training in residency, and then maintained in continuing education programs, education that forms the foundation of physician care for all patients. In retrospect, that thoughtful, deliberate approach to defining our project generated the most important and enduring attribute of our series as it grew and matured through its successive editions: specifically, that our

textbook should focus on the needs of future leaders in this new field, those who would choose to undergo training at the post-graduate level—that is, fellows in Gerontology and Geriatric Medicine.

Through our textbook we have hoped that physicians will be enriched and continuously kept current from its concentration upon the special needs of their older patients. Clinical topics have been integrated with chapters summarizing the aging process across the lifespan from conception to death (gerontology), but honing down on those older than 65, 75 (my personal definition as the threshold to old age), and, perhaps most germane to our special contributions as geriatricians, the “oldest old,” those older than 85 (the group to which I now belong!) in whom the art and science of caring for the most complex and vulnerable can be most appreciated. And with the “Aging Tsunami” of retiring baby-boomers upon us, our mission to enhance the practice of all professionals and caregivers in managing such patients through our textbook is all the more urgent. Thus, it has been gratifying to observe the expansion of our original focus on physicians training in geriatrics to encompass the educational needs of trainees in the wide range of health professions that are required to meet the clinical challenges presented by older adults with complex health care problems.

I am especially pleased that one of the editors of the eighth edition, Stephanie Studenski, has worked with other leaders in the field to document the range of geriatrics training experiences for physicians and other health professionals as summarized in the new chapter, Geriatrics Around the World. This special expertise will serve them well as future leaders in health care as it becomes progressively skewed toward caring for older patients.

Thus, it will be incumbent upon editors of future editions of this textbook to remain abreast of leading edge developments in our field, which promises to

become ever more sophisticated and challenging as aging citizens continue to enjoy increasing healthspan as well as lifespan.

This textbook remains the most enduring icon of my career in the field of Gerontology and Geriatric Medicine. It is with pride and confidence that I predict that the education of future generations of all clinicians and researchers who focus on the care of older patients will be enhanced by the eighth edition and future editions of this textbook.

On behalf of the editors, it is an honor and privilege to provide this preface to Hazzard’s Geriatric Medicine and Gerontology, Eighth Edition. This textbook has become a mainstay of the rapidly developing field of geriatric medicine. Building on the textbook’s already rich history since it was first published in 1985, the eighth edition emerges renewed and vibrant. This is the third edition of this textbook to carry the name of its founding editor Bill Hazzard in its title. We are pleased that Bill has contributed a foreword to the eighth edition, providing his view of the critical importance of fellowship training in geriatrics to the future of our field.

Planning for the eighth edition began in 2019, but the chapters were written and revised during the height of the COVID-19 pandemic. Thus, we are even more grateful than usual to the many contributors who found time to do their work on the book despite the stresses imposed on both work and personal time by the pandemic. One new editor has played a critical role in the revitalized eighth edition of this textbook: Kenneth Schmader. We recruited Ken to join us in 2019 because of his leadership in the field and many academic accomplishments. Little did we know then how timely that choice was, as Ken is a world leader in infectious diseases in the older adult population, especially viral illnesses and in vaccines to prevent them. As a result, the eighth edition includes extensive coverage of the COVID-19 pandemic and its especially devastating impact on vulnerable older adults.

Chapter 108, Influenza, COVID-19, and Other Respiratory Viruses, is primarily focused on the pandemic. As summarized in Table 1, COVID-19 is covered in 25 other chapters as well, including many with a specific section devoted to it.

TABLE 1 ¦ COVID-19 COVERAGE IN THE EIGHTH EDITION

In addition to Ken, the eighth edition’s editorial team includes me (my sixth edition); Joe Ouslander (his fifth edition); Sanjay Asthana, Kevin High, and Stephanie Studenski (their third edition); and Christine Ritchie and Mark Supiano (their second edition). Fortunately for all of us, Bill Hazzard has stayed actively involved as Editor Emeritus and senior advisor. The eighth edition acknowledges and recognizes the worldwide growth of the field of geriatric medicine. Overall, our authors are not only a large and diverse group including many geriatricians but also a substantial number of subspecialists from a range of medical and surgical disciplines. In addition, multiple health profession disciplines are represented among the authors.

The eighth edition is substantially different from its predecessors, reflecting the continued growth and increasing sophistication of geriatrics as a defined medical discipline. Vitality and continued rejuvenation have been enhanced through the addition of seven chapters (see Table 2). In addition to the new chapters, we have carried out a major restructuring of the book to put more emphasis on the growing knowledge base for key topics in the field, Parts I–IV: Principles of Gerontology, Principles of Geriatrics, Geriatric Conditions (those health problems occurring almost exclusively in older people), and Principles of Palliative Medicine and Ethics. In parallel we

have deemphasized the subspecialty-oriented Part V: Organ Systems and Diseases by combining many of the topics and focusing them more on geriatric aspects of these age-related diseases. Thus, for the first time in this book’s history, more than half of the chapters (in fact, two-thirds, 72 of 108) are in Parts I–IV and only one-third are in Part V. The revised structure aligns closely with the geriatric “M’s” of Age-Friendly Care—notably in Part II, Section B: Age-Friendly Care Across Settings (Chapters 12–21), Medications (Chapter 22), Mobility (Part III, Section B, Chapters 49–55), Mentation (Part III, Section C, Chapters 56–66), and What Matters Most (Chapters 7, 24, 25, 41, and 67–72). Furthermore, total number of chapters has been reduced from 130 in the seventh edition to 108, and the total pages of text have been reduced by 13% despite increasing the number of tables and figures.

TABLE 2 ¦ NEW CHAPTERS IN THE EIGHTH EDITION

As a result of these changes, many more chapters have been written by geriatricians and fewer by subspecialists with a geriatrics interest. In addition, a growing number of authors are women. In the eighth edition, nearly half of all chapters have a woman first author (52/108) and 70% have at least one female author (73/108), up from 60% in the seventh edition.

Contrast these numbers with the first edition of the book (7/84 with a woman first author and 11/84 with at least one female author). On a personal note, as I reviewed the contributors to that first edition, I realized that the only one left of those authors who has contributed to the eighth edition (in fact to all

editions) is me! We do take seriously the goal of recruiting new authors and transitioning out the older ones.

This is the second edition of the book to be published in full color, thereby greatly enhancing the many illustrations and figures included. To promote and facilitate the book’s utility as an educational resource for Geriatric Medicine fellows in training and others, each chapter includes learning objectives and key clinical points. These have been linked to one or more of the Geriatric Fellowship Curriculum milestones to allow easy access by readers. This educational emphasis is highly relevant to Bill Hazzard’s comments in the Foreword. A major step forward for this textbook is the electronic version, which is now widely available online and will continue to be available as the eighth edition. One of the original goals of working with McGraw Hill as the publisher of this textbook was to provide a link with Harrison’s Principles of Internal Medicine. This link was greatly strengthened with the electronic version of Hazzard’s Geriatric Medicine and Gerontology, which became part of McGraw Hill’s AccessMedicine.com collection with publication of the sixth edition. Access Medicine includes not only our textbook and Harrison’s Principles of Internal Medicine, but also multiple other important books in the clinical library of McGraw Hill. We are especially pleased that students of the health professions, both undergraduate and postgraduate, have full access to our textbook through the electronic version if they are at an institution that subscribes to AccessMedicine.

Thus, just as our population is inexorably aging, and medicine is faced with an ever-growing number of older patients with multiple and complex problems, we have been able to bring together the best minds and leaders in the field to provide authoritative guidance. Our authors present a highly diverse and dynamic range of thinking that has not previously existed in our textbooks of geriatric medicine. We are now reaching a broader audience through the availability of the electronic version of the textbook. We have kept it a living and growing document that encompasses the rapid stream of new information, which is helping us to provide more compassionate and effective care to the rapidly growing population of older adults.

The strong and effective working relationship that we have with McGraw Hill is made possible by the outstanding efforts of Leah Carton, Associate Editor for the McGraw Hill geriatrics publishing program; Kim J. Davis, Managing Editor; and their McGraw Hill colleagues who have ensured the

progress of the publication and the important next steps in the textbook’s evolution. We are grateful for the help of Karen G. Edmonson, who managed the seventh edition of the book and initiated planning for the eighth edition before leaving McGraw Hill, and for the continued support of James F. Shanahan, publisher at McGraw Hill, who was instrumental in the initial publication of this textbook and served as its Managing Editor for the first six editions. We especially appreciate the efforts of Nancy Woolard from Wake Forest University School of Medicine, who has served as a senior editorial project manager for multiple previous editions. Her role for the current edition has been critical to provide a strong link to our past history and as the final common pathway for assembly of the eighth edition. We thank Drs.

Rachel Brenner and Celia Pena Heredia, Geriatric Medicine fellows at the University of Utah, for their helpful advice mapping the fellowship curricular milestones to relevant chapters in the textbook.

Biology of Aging and Longevity Demography and Epidemiology Immunology and Inflammation Psychosocial Aspects of Aging

Aging is the process that converts young adults, most of them healthy and in no need of assistance, into older adults whose deteriorating physiologic fitness leads to progressively increasing risks of illness and death. The effects of aging are so familiar to health professionals and aging adults that they are viewed as immutable, taken for granted, an arena in which diseases and their treatments take place, but not subject to intervention or modulation. The major discovery in biogerontology is that this old-fashioned viewpoint is wrong, and that the aging process can be delayed or decelerated in mammals like us by simple manipulations of nutritional signals and genetic circuits similar to those already well-documented in people. It is now routine to extend lifespan, in rats and mice, by about 40%. This effect is, remarkably, 10 times greater than the increase in active life expectancy that would ensue from elimination of all neoplastic illnesses, or all heart attacks, in a human population. As importantly, genetic and pharmacologic interventions that increase longevity typically delay or even prevent many classes of age- associated diseases, such as cancer, metabolic decline, and neurodegeneration. It thus seems likely that a more detailed understanding of the factors that determine aging and the processes by which aging increases the risk of such a wide range of lethal and nonlethal illnesses and disabilities could, in the foreseeable future, have a profound impact on human health and preventive medicine.

Aging is a mystery, in the same sense that infectious disease was once a mystery, and consciousness still is an area of investigation in which well- informed researchers cannot be certain that they have selected a line of investigation bound to be productive. For a long time, most published papers

in biogerontology journals consisted of descriptions of the ways in which young mice, rats, or people differed from older ones. This descriptive era has been superseded by one focused on specific molecular hypotheses about the key factors that regulate aging and on specific genes, drugs, and nutritional manipulations that could delay aging.

This question—what is aging?—is posed not as an invitation to semantic quibbling, but to initiate reexamination of facts so familiar that they are seldom examined. A case history of an individual who has mild arthritis, some loss of hearing acuity, some evidence of incipient cataract, loss of muscle mass and strength, a progressive decline in capacity for aerobic exercise, troubles with learning and remembering, and an increased vulnerability to infectious illness would lead any physician to assume that the individual described is a man or woman age 60 or older. But the list of signs and symptoms refers with equal accuracy to a 20-year-old horse, a 10-year- old dog, or a 2-year-old mouse. The specific list of deficits and impairments shifts a bit from person to person, and from species to species, but it is extremely rare to find an 80-year-old person, a 3-year-old mouse, or a 14- year-old dog that has avoided all of these age-associated problems. The aging process is synchronized, in that it is common to see all of these difficulties in older people, horses, dogs, and mice, but rare to encounter any of them in young adults just past puberty. This synchrony is the central challenge in biological gerontology: How is it that such a process affects so many cells, tissues, organs, and systems at a rate that varies, even among mammals, over a 100-fold range from the shortest-lived shrews to the longest-lived whales? Structural features of shrews, mice, dogs, and people are remarkably similar at scales from the arrangement of DNA and histones in the nucleus, to the architecture of most tissues, to the role of the central nervous system (CNS) and endocrine systems in regulating responses to heat and cold, hunger and thirst, infection, and predators. Why, then, in molecular terms, will the eye, kidney, immune system, brain, and joints of a mouse last only 2 to 3 years under optimal conditions, while the same cells and organs and systems persevere for 50 or more years in people, and longer still in some species of whales?

Key Clinical Points

Biological aging predisposes older individuals to disease and increased mortality risk.
Dietary restriction (DR) extends lifespan and promotes late life health in diverse taxa, including mammals.
Interventions that slow the aging rate also delay or even prevent multiple age-associated pathologies simultaneously, such as cancer, neurodegeneration, metabolic syndrome, renal dysfunction, and many others.

The definition proposed at the beginning of this chapter—aging as a process for turning young adults into distinctly less healthy old ones—is straightforward enough to appear simple-minded, but in practice draws some prominent distinctions. In this view, aging is not a disease. Diseases are certainly among the most salient consequences of aging, but aging produces many changes not classified as diseases, and many diseases also affect young people. Similarly, lifespan and mortality risks are influenced by many factors besides aging. Thus, evidence that a gene or diet or public health measure has altered life expectancy, upwards or downwards, does not imply that the effects have been achieved by an effect on aging. In the context of the whole organism definition of aging used in this chapter, the sequence of changes that affect the quality of a fine burgundy wine or mature cheddar cheese, or changes that cell lines undergo in culture, do not qualify as aging.

From a biological standpoint, it is critical to see the distinction between aging and development. Development creates a healthy young adult from a fertilized egg and is strongly molded by natural selection. Genetic mutations that impair development, creating a clumsy falcon, a near-sighted chipmunk, or a chimpanzee uninterested in social cues, are rapidly weeded from the gene pool. But the force of natural selection diminishes dramatically at ages beyond those typically reached by members of a given species. Mice, for example, typically live only 6 months or so in the wild, before they succumb to predation, hypothermia, starvation, or other natural hazard. There is therefore strong selective pressure against mutations that cause cataracts in the first few months of mouse life, but little or no pressure against genotypes that postpone cataract formation for 2 years, an age seldom reached by mice in their natural environment. Mice protected, in a laboratory setting, against predation, starvation, and other risks typically do develop cataracts in their second or third year. In wolves, however, a genotype that delayed cataracts for only 2 years would be a disaster; natural selection favors wolf genes that preserve lens transparency for a decade or more. A similar process, working on our ancestors in environments where survival to 15 was common, but survival to 55 distinctly uncommon, has filled our own genome with alleles that postpone cancer, osteoarthritis, coronary disease, Alzheimer disease, presbycusis, cataracts, sarcopenia, immune senescence, and many other familiar maladies, for about 50 to 60 years. Thus, although aging and development seem, superficially, to be similar processes in that both lead to changes in form and function, they are different in a fundamental and critical way: Development is molded directly by the forces of Darwinian selection, and the changes of aging are the consequence of the failure of these selective processes to preserve function at ages seldom reached by individuals in any given species.

The definition of aging as a process that turns young adults into old ones conflicts with a view of aging as instead a collection of processes, some that lead to arterial disease, some that affect endocrine function, some that impair cognition or cause neoplastic transformation, etc. Each of these ailments is itself the outcome of a complex interaction among many factors, including genes, diet, accidents, viruses, toxins, and the environment. Furthermore, each of these diseases, and many others, seems an inextricable part of aging.

As a result, it originally seemed implausible to regard aging as less complex than its (apparent) constituents. Considering aging as a unitary process, potentially susceptible to modulation, rather than as a collection of complex processes, has thus seemed, to some, to be an oversimplification.

However, two lines of evidence support the merits of the view of aging as a unitary process, with its own (still incompletely defined) physiologic and molecular basis, which underlies and tends to synchronize the multiple changes seen in older individuals. The first of these discoveries was caloric restriction (CR): The observation that rodents allowed to eat only 60% of the amount of food they would voluntarily consume live 40% longer than controls permitted free access to food, discussed in greater depth subsequently. This observation, first made in the 1930s, has been repeated in more than a dozen species in scores of laboratories. Studies in rhesus monkeys have produced suggestive evidence that similar benefits may accrue in our own order of mammals. The key point is not merely that lifespan is extended, but that nearly all of the consequences of aging are coordinately delayed. CR delays changes in cells that proliferate continuously (such as gut epithelial cells), cells that can be triggered to proliferate when called upon (such as lymphocytes), and those that never proliferate (such as most neurons), as well as on tissues that are extracellular or acellular (such as lens tissue and extracellular collagen fibrils). CR delays aspects of aging characterized by excess proliferation, such as neoplasia, and also those characterized by failure to proliferate (such as immune senescence). It delays or decelerates age change at the tissue level (such as degradation of articular cartilage) and those involving complex interplay among multiple cells and tissues (such as loss of cognitive function and endocrine control circuits).

Because CR alters, in parallel, so vast an array of age-associated changes, it seems inescapable that these many changes, distinct as they are, must be in some measure coordinately timed, that is, synchronized or delayed by a mechanism altered by caloric intake. This synchrony does not reflect a “clock” that turns on molecular and cellular damage at a set time, producing programmed changes of the sort common in development. Synchrony reflects, instead, processes that can, through unknown links, delay and decelerate age- associated damage in multiple cells and tissues in parallel, to an extent that varies widely across species.

A second, more recent, set of experiments leads to the same inference. In 1996, Bartke and his colleagues reported that Ames dwarf mice, in which a

developmental defect in the pituitary impairs production of growth hormone (GH), thyrotropin, and prolactin, show an increase of more than 40% in both mean and maximal lifespan compared to littermates with the normal allele at the same locus. Since then, studies of this mutant, and the closely similar Snell dwarf mouse, have documented delay in kidney pathology, arthritis, cancer, immune senescence, collagen cross-linking, cataracts, and cognitive decline, making a strong case that these genetic changes in endocrine levels do indeed modulate the aging process as a whole, with consequent delay in a very wide range of age-synchronized pathology. Since 1996, mouse researchers have documented increased lifespan in dozens of other genetically altered mouse strains, some of which show lower levels of or responses to GH, and/or its downstream mediator IGF-1.

Studies such as these justify a paradigm shift in thinking about aging and its relationship to disease. The new framework includes three key tenets: (1) the aging process, despite the complexity of its many effects, can be postponed by a single, coordinating mechanism; (2) the rate at which aging progresses can be decelerated in mammals as well as in other taxa; and (3) the time of onset and pace of many age-associated diseases are closely linked to the aging rate. From this perspective, a fundamental challenge to biogerontologists is to develop and test models of how age-dependent changes can be delayed, during middle age, to maintain relatively healthy people or mice or worms. Studies of aged individuals, as opposed to studies of aging, are relevant to this challenge only insofar as they are exploited to generate or test ideas about coregulation and synchrony, rather than disease- specific pathogenesis. The key resource for meeting the challenge is not comparisons between young and old donors, but rather comparisons between young or middle-aged adults who are known to be aging at different rates because of genetic differences or exposure to dietary or pharmacologic intervention. Fortunately, the same experiments that have documented the malleability of aging rate have produced sets of animals that do indeed age at slower-than-normal paces. With luck, future studies may produce at least tentative answers to the two key questions in biogerontology: How does aging produce the signs and symptoms of aging, and what controls the rate of this process in mammals?

Modern aging biology might be considered to begin in the early 1990s, when studies of genetically tractable invertebrate models, principally the budding yeast Saccharomyces cerevisiae, the nematode roundworm Caenorhabditis elegans, and the fruit fly Drosophila melanogaster, began to identify ways in which the lifespan of these simple organisms can be extended. Two decades of work in these systems have led to a set of guiding principles: (1) single- gene mutations—lots of them—can extend lifespan, (2) groups of genes with related functions often influence lifespan through common mechanisms, thereby revealing defined biological pathways that modulate aging, (3) many biological processes regulate aging in a conserved manner, in diverse phyla separated by billions of years of evolutionary time, and (4) consequently, aging studies in simple model organisms—with all of their advantages in terms of facile genetics and rapid experimental turnaround—are a valuable “breeding ground” for directed studies of similar processes in vertebrate animals such as mice.

One of the earliest manipulations to prolong healthy lifespan involved diet. Mice or rats fed approximately 30% or 40% less food than they would ordinarily consume typically live up to 40% longer than freely fed animals. Fruit flies intermittently starved are also long-lived. Remarkably, rodents and flies exposed to CR stay healthy and active, with intact physical, sensory, and cognitive function, at ages at which most of the controls have already died. In mice, CR extends lifespan if initiated at very young ages (eg, at weaning), or when started early in adulthood (eg, at 6 months, in a species where puberty occurs at 2 months and median survival is normally about 28 months).

Whether CR diets extend lifespan when initiated in animals already older than half the median lifespan is controversial, with some early studies suggesting little or no response, and some more recent experiments showing a beneficial effect. Lifespan extension by dietary manipulations appears to represent an evolutionarily conserved effect, and it occurs in taxa as diverse as daphnia, worms, flies, spiders, and rodents.

Historically, the beneficial effects of dietary manipulations have been attributed to a reduction in the caloric content of the food. Indeed, most of the early rodent and fly studies were performed by reducing availability of all dietary components (eg, protein, carbohydrates, and lipids). More recently, however, comprehensive experiments in flies and mice that cover a broad

dietary landscape suggest that individual macronutrients do not act independently, nor is caloric value the primary predictor of dietary effects on lifespan. Nutrients interact, and it is their balance that appears to be critical (Figure 1-1). A diet containing relatively low protein (in relation to other macronutrients) commonly results in the longest lifespan. This broader view of dietary composition as a major determinant of health and lifespan had led to the term “dietary restriction” largely replacing the traditional term “caloric restriction.”

FIGURE 1-1. Dietary composition, not caloric value, specifies lifespan in Drosophila. (A) A diet response surface that characterizes the lifespans of female fruit flies across a range of 25 different diets composed of different concentrations of sugar and yeast, which are the two macronutrients in the Drosophila diet. Longevity is maximized at intermediate concentrations of both nutrients, and trends in lifespan are not coincident with differences in the caloric value of the food, as evidenced by the significantly different lifespans observed in isocaloric diets. (B) When lifespans from each of the 25 diets are rank-ordered, there is little association with amount of calories the flies consume (bottom panel), but there is a significant negative correlation between lifespan and a measure of dietary imbalance, which is proportional to the difference in nutrient concentrations (top panel). (Adapted with permission from Skorupa DA, Dervisefendic A, Zwiener J, et al. Dietary composition specifies consumption, obesity, and lifespan in Drosophila melanogaster. Aging Cell. 2008;7[4]:478–490.)

While comprehensive analysis of the dietary landscape is prohibitively expensive in primates, diminished food intake in rhesus monkeys can delay many indices of aging and age-related disease. Results on lifespan extension have been inconsistent between studies, perhaps due to subtle differences in diet composition, food intake by control animals, and the intensity of veterinary intervention. In humans, DR leads to dramatic improvements in

lipid profile, blood pressure, and other cardiovascular parameters. Whether or not DR without malnutrition would extend longevity in humans is unknown, though population studies hint that the answer is likely to be yes.

How DR promotes longevity mechanistically remains uncertain and so is the subject of active investigation. Invertebrate models have revealed that the health and lifespan benefits associated with DR require coordinated changes in specific signaling pathways and in gene expression. Biological processes that have been implicated in the response include stress resistance, mitochondrial respiration, and protein synthesis. Some of the effects of DR also appear to be in part independent of actual nutrient consumption, suggesting that animals may respond to the perception of nutrient availability in a way that promotes survival.

Some of the candidate mechanisms of DR identified in invertebrates may also be active in mammals. The effects of severe DR on rodent lifespan do not depend solely on avoidance of obesity. Although DR rodents have far lower adiposity than control animals, this is not due simply to a global reduction in the overall metabolic rate. In fact, in some tissues, mitochondrial respiration actually increases in response to DR. DR does, however, increase the efficiency of the mitochondrial electron transport chain, and reduces levels of damage attributable to reactive oxygen species (ROS) in certain tissues such as the liver. Possible mechanisms of DR effects in rodents, which are not mutually exclusive, include alterations in nutrient- responsive signaling pathways, increases in stress-resistance pathways including resistance to oxidative injury, diminished inflammatory responses, changes in stem cell self-renewal, alterations in the ratio of visceral to subcutaneous fat, alterations in cellular properties related to protein metabolism, and many others, each plausible, but none of them proven at this point.

The benefits of specific nutrient manipulations have been highlighted by experiments that alter the availability of individual amino acids, either acutely or throughout the lifespan. Rats fed a diet containing much reduced levels of the essential amino acid methionine live 40% longer than rats on a standard diet, and there is a similar, though smaller, effect in mice. The lifespan effect in mice is seen even when methionine restriction (MR) is not begun until the mice are well into adulthood, roughly the equivalent of a 35- year-old person. These animals are not calorically restricted—they eat more calories, per gram of lean body mass, than control rats, and rats pair-fed

normal food to match the total caloric intake of an MR rat show a much smaller degree of lifespan extension. Diets in which amino acids are restricted could, in principle, affect tissue health and organism aging by causing changes in protein translation or rate of protein turnover, by changes in DNA methylation (which depends on metabolites of methionine), by alterations in levels or distribution of the antioxidant glutathione (also a metabolite of methionine), by changes in hormone levels (MR mice show low levels of insulin, glucose, and IGF-1), by changes in hydrogen sulfide production, and/or by induction, through hormesis, of augmented stress response pathways at the cellular level. Work in flies suggests that methionine might be more influential than other amino acids in this context, though parallel studies in mammals have not been attempted. Comparisons of similarities and differences between amino acid restriction and full DR in rodents are likely to prove highly informative. Restriction of food, or of protein alone, for a period of several days prior to ischemic or surgical injury, or prior to chemotherapy, leads to better outcomes in rodents, but the extent to which such benefits reflect the same pathways through which long- term DR extends lifespan is not yet clear.

Broadly speaking, mice and rats on DR diets show delay or deceleration in a very wide range of age-dependent processes, including neoplastic and nonneoplastic diseases, changes in structure and function of nearly all tissues and organs evaluated, endocrine and neural control circuits, and ability to adapt to metabolic, infectious, and cardiovascular challenges. Mouse stocks that have been engineered for vulnerability to specific lethal diseases, such as models of lupus or early neoplasia, also tend to live longer when placed on DR.

In the 1990s, the Kenyon and Ruvkun laboratories led research showing that loss of function in key components of the nematode C elegans insulin/IGF receptor homolog signaling pathway, including insulin-like receptor daf-2, results in large increases in lifespan in this organism, and that this benefit is dependent on a FoxO transcription factor. Conserved elements of this pathway were soon shown to have similar effects on lifespan in the fly, in brewer’s yeast, and eventually in mice (Figure 1-2). FoxO proteins regulate expression of genes involved in stress resistance, DNA repair, cell cycle arrest, apoptosis, metabolism, and other processes, in a cell- and tissue-

specific manner. Over subsequent decades, dozens of studies in worms and flies have revealed that signaling by invertebrate insulins play a major, evolutionarily conserved role in limiting longevity.

FIGURE 1-2. Research in simple model systems reveals the first molecular pathway that modulates aging. (A) One of the first single-gene manipulations capable of significantly extending the lifespan of an organism was discovered in the nematode worm, Caenorhabditis elegans. When a mutation was introduced into the gene daf-2, which encodes the only insulin- like growth factor (IGF) receptor in the worm, the animals lived over twice as long as the control animals. (B, C) Subsequent studies in (B) the fruit fly, Drosophila melanogaster, which also targeted its sole insulin-like receptor, and in (C) the brewer’s yeast, Saccharomyces cerevisiae, which targeted the insulin-responsive Akt protein kinase, revealed that disruption of insulin/IGF-like signaling extended the lifespan of these organisms as well. (D) A member of the FoxO transcription factor family was soon found to be required for these life-extending effects, thus establishing the first evolutionarily conserved molecular pathway that influences aging. (A, Data from Kenyon C, Chang J, Gensch E, et al. A C. elegans mutant that lives twice as long as wild type. Nature 1993;366[6454]:461–464; B, Data from Tatar M, Kopelman A, Epstein D, et al. A mutant Drosophila insulin receptor homolog that extends life-span and impairs neuroendocrine function. Science. 2001;292[5514]:107–110; C, Data from Fabrizio P, Pozza F,

Pletcher SD, et al. Regulation of longevity and stress resistance by Sch9 in yeast. Science. 2001;292[5515]:288–290; D, Reproduced with permission from Scott Pletcher.)

The observation that longevity in mice could be improved by reduction of hormones in the insulin/IGF family provided a key foundation for exploiting comparative cell biology in biogerontology research. Subsequent work then showed that the lifespan benefit seen in Ames dwarf mice is also present in Snell dwarf mice, whose endocrine defects are very similar to those of Ames dwarfs, and in mice that lack the GH receptor (GHR-KO mice). This last observation, together with documented lifespan extension in mice producing low levels of GH-releasing hormone (GHRH), the hypothalamic factor that stimulates GH secretion by the pituitary, and in mice lacking the receptor for GHRH, suggests that longevity of the Snell and Ames dwarf mice is due mainly to loss of GH and/or IGF-1 signals. Studies of Snell and Ames dwarf mice, and of GHR-KO mice, have shown that the exceptional longevity of these mice is accompanied by a delay or deceleration of age-dependent changes in T lymphocytes, skin collagen, renal pathology, lens opacity, cognitive function, and neoplastic progression. Taken with the lifespan data, these observations suggest strongly that these mutations, like DR, act to slow the aging process itself (Figure 1-3). These mutations increase healthy lifespan in both male and female mice, with some evidence for stronger effects in females.

FIGURE 1-3. Mice carrying the Snell dwarf mutation are one-third of the size of their normal littermates, because the mutation diminishes production of growth hormone by the pituitary (A). This mutation increases mean and maximum lifespan by about 40% (B), and reduces the severity of kidney lesions at death among many other forms of late-life illness (C). Mice carrying a dominant mutation for Huntington disease (HD) perform less well than wild-type (WT) control mice on a balance beam task (D), but the HD gene does not produce corresponding symptoms when it is placed on a Snell dwarf background. (A, Reproduced with permission from Richard Miller; B, Reproduced with permission from Flurkey K, Papaconstantinou J, Miller RA, Harrison DE. Life span extension and delayed immune and collagen aging in mutant mice with defects in growth hormone production. Proc Natl Acad Sci U S A. 2001;98[12]:6736–6741; C, Data from Vergara MM, Smith-Wheelock JM, Harper R, et al. Hormone-treated Snell dwarf mice regain fertility but remain long-lived and disease resistant. J Gerontol A Biol Sci Med Sci. 2004;59[12]:1244–1250; D, Data from Tallaksen-Greene SJ, Sadagurski M, Zeng L, et al. Differential effects of delayed aging on phenotype and striatal pathology in a murine model of Huntington disease. J Neurosci. 2014;34[47]:15658–15668.)

It is uncertain whether longevity in these mutant or engineered mice reflects loss of GH signals per se, or a decline in levels of IGF-1, whose production by the liver is GH-dependent. Mice with lower levels of the receptor for IGF-1 have inconsistent findings, ranging from a lifespan benefit in female mice, to little or no benefit in either sex.

Perhaps the strongest evidence for a direct role of IGF-1 comes from reports of increased lifespan in mice lacking the protease pregnancy- associated plasma protein A (PAPP-A). PAPP-A is thought to increase levels

of free, active IGF-1 in many tissues by removal of binding proteins that ordinarily sequester IGF-1 and inhibit its activity. Thus genetic deletion of PAPP-A would be expected to diminish IGF-1 action in some tissues, without an effect on circulating or local GH levels. Clarifying details of local control of GH and IGF-1 action could have important implications for human applications, if it proves possible to target inhibition of GH or IGF-1 signals specifically to cell types that modulate aging rate, and thus avoid side effects that might occur if GH or IGF-1 signals were blocked throughout the body. Suppression of IGF-1 signaling in female mice using a neutralizing antibody can extend lifespan in older animals, highlighting the therapeutic potential of targeting this pathway.

Some of the longevity effects in Ames and Snell dwarf mice appear to reflect adjustments to limits in GH levels in the first few weeks of life, between birth and weaning 3 weeks later. Ames dwarf mice injected daily with GH, starting at 2 weeks, fail to show the increased lifespan characteristic of this mutation and also resemble nonmutant control mice in other ways, including lowered cellular stress resistance and diminished hypothalamic inflammation. GH injections started at 4 weeks, however, do not produce such an effect. Conversely, restricting the amount of milk available to normal mice, in their first 3 weeks of life, can lead to a 10% to 20% increase of lifespan; such mice show lower than normal levels of IGF-1 at the end of the nursing period. Thus it appears that the availability of nutrients, perhaps reflected as higher levels of circulating GH and IGF-1 in the first few weeks of life, may produce long-lasting changes in cellular and hormonal properties that persist throughout adult life and affect mortality risks in old age (Figure 1-4).

FIGURE 1-4. Early-life hormonal and nutritional status can have major effects on late-life survival and disease. The left panel shows an experiment in which Ames dwarf mice were

given injections of growth hormone (GH) for an 8-week period beginning at 2 weeks of age. These hormone-injected mice had survival patterns similar to that of normal mice (WT controls), and therefore much shorter than Ames mutant mice (green) that had only saline injections at early ages. The right panel shows a complementary experiment, in which genetically normal mice were partially deprived of milk (“CL” for “crowded litter”) by adding extra pups during the suckling phase, from birth to 3 weeks. This transient milk deprivation led to a substantial increase in lifespan in the CL mice. (A, Reproduced with permission from Panici JA, Harper JM, Miller RA, et al. Early life growth hormone treatment shortens longevity and decreases cellular stress resistance in long-lived mutant mice. FASEB J. 2010;24[12]:5073–5079; B, Adapted with permission from Sun L, Sadighi Akha AA, Miller RA, et al. Life-span extension in mice by preweaning food restriction and by methionine restriction in middle age. J Gerontol A Biol Sci Med Sci. 2009;64[7]:711–722.)

A second nutrient-sensing pathway, the amino acid–sensing TOR pathway, interacts extensively with insulin and IGF signaling in complex ways, some of which are diagrammed in Figure 1-5. TOR plays a major role in regulating protein translation rates and other key target pathways in response to both external cellular stress, the available supply of amino acids and carbohydrate fuels, and hormonal signals. Downregulation of TOR signaling was initially shown to extend lifespan in flies, with evolutionary conservation later demonstrated in nematode worms and then in yeast. It is likely that many dietary interventions that extend lifespan recruit TOR- related mechanisms to affect aging, and inhibition of TOR function by the drug rapamycin can extend longevity in rodents and invertebrates (as discussed subsequently). TOR exists in two distinct molecular complexes, called mTORC1 and mTORC2, which have a wide range of effects on cell size and shape, responses to stress and nutrient levels, as well as protein synthesis and responses to glucose and insulin. Experimental work to distinguish the distinct, but interacting, effects of mTORC1 and mTORC2 activation in specific cell and tissue types is now under way. Signals mediated by the TOR complexes interact with those generated through insulin action.

FIGURE 1-5. Insulin–IGF (insulin-like growth factor) signaling and mTOR (mammalian target of rapamycin) signaling regulate lifespan. Insulin and IGF binding to their cognate receptors (R) activates the intracellular kinase AKT. AKT in turn phosphorylates a large number of cellular substrates, including members of the FoxO transcription factor family, leading to their nuclear export and inactivation. Nuclear FoxO family members regulate stress responses and lifespan in multiple organisms, including mammals. mTOR kinase is found in two distinct cellular complexes, TORC1 and TORC2. TORC1 inhibits autophagy and promotes protein translation through its downstream effectors, 4EBP1 and S6K1. Inhibition of TORC1 has been most closely linked to longevity, although TORC2 may play a role as well. (Reproduced with permission form David Lombard.)

Building on interest in TOR signaling and its effects on protein translation, work in invertebrates and increasingly in mammals has revealed fundamental links between the maintenance of proteostasis and longevity.

Proteostasis refers globally to the processes that improve the quality and function of cellular proteins, collectively termed the proteome. It includes regulation of protein translation, folding, damage repair, and degradation. Autophagy is a process by which damaged cellular proteins and even whole

organelles such as mitochondria are degraded in lysosomes. In invertebrates, intact autophagy systems are required for longevity extension by essentially all interventions that increase lifespan. Increased expression of the autophagy protein ATG5 extends mouse lifespan and improves neuromuscular function and glucose tolerance in old mice. Rapamycin, which extends lifespan in many different organisms, decreases translation of many cellular proteins, while promoting increased autophagic function. Snell and GHR-KO mice show augmented levels of a specific form of autophagy, “chaperone- mediated autophagy,” which can affect levels of proteins involved in cell cycling, fat synthesis, and mRNA translation. Collectively, these findings indicate that maintenance of proteostasis is a key requirement of longevity.

Sirtuin proteins, which play a major role in aging in yeast, have captured the public interest and sparked robust debate in aging circles. The sirtuins are a family of protein deacylases that consume the metabolic cofactor NAD+ during catalysis. Cellular NAD+ levels increase under conditions of fasting or DR, in a tissue-type specific manner. In light of their NAD+ requirement, sirtuins have been implicated as energy sensors and potentially as mediators of some of the benefits of DR. In yeast, worms, and flies, sirtuin overexpression extends longevity, albeit more modestly in worms and flies than initial reports suggested. Mammals possess seven distinct sirtuins; these are a diverse protein family, from the standpoint of biochemical activity, protein targets, and localization. Mammalian sirtuins target their protein substrates via deacetylation, or removal of other posttranslational modifications, to regulate a wide range of proteins involved in gene expression, DNA repair, metabolism, and many other processes. Three sirtuins are present in the mitochondrial matrix, where they regulate intermediary metabolism and other aspects of mitochondrial function.

In mammals, most studies have focused on SIRT1, the closest homolog of the yeast SIR2 protein. Whole-body overexpression of SIRT1 does not increase overall lifespan in mice, although it is protective against age- associated metabolic dysfunction and certain forms of neoplasia.

Overexpression of SIRT1 in the brain only, however, does extend mouse lifespan. Overexpression of the sirtuin SIRT6 throughout the body also extends lifespan in male mice. SIRT6 promotes metabolic homeostasis and enhances genomic stability; it will be important to elucidate which of

SIRT6’s many functions are most important in its prolongevity role. For example, sequence variations among SIRT6 homologs across different mammalian species may contribute to altered DNA repair efficiencies, and even to differences in lifespan.

Beginning with resveratrol, a series of small molecule activators of SIRT1 have been developed. In mice, these drugs show some beneficial effects, particularly in the context of dietary challenge such as high-fat feeding. There are continued controversies regarding these agents, particularly focused on the extent to which they target SIRT1 directly, versus exerting indirect effects through other signaling molecules, such as AMPK. Nevertheless, these or similar agents could conceivably find utility in treating age-associated metabolic dysfunction in humans.

Mutations that extend lifespan in invertebrates typically render the animals resistant to multiple forms of lethal injury, whether the threat comes from oxidative agents, heat, heavy metals, or irradiation. Genetic dissection of the relevant pathways—which must have evolved very early in the evolutionary tree, that is, prior to the common ancestor shared by worms, flies, and humans—has shown, surprisingly, that in normal, nonmutant worms, the levels of stress resistance, and thus resistance to aging, are actively diminished by inhibition of specific DNA-binding transcription factors, members of the FoxO family (see Figure 1-5). These pathways are retained by evolutionary pressures because they provide reproductive advantages in the natural environment, in which animals must be able to quickly take advantage of transient access to nutrients. Activation of FoxO proteins in the laboratory produces mutant animals that are not ideally suited for natural conditions, but which are resistant to many kinds of stress and which age more slowly than normal. Studies of gene expression patterns in the long- lived mutant worms have shown that the FoxO proteins can regulate transcription of over 100 genes that together protect against many different forms of cellular damage. The list includes enzymes that destroy free radicals, heat shock proteins, and other chaperones that guard against misfolded proteins, proteins that protect against infection, and chelating agents that bind toxic metal ions, among others.

Induction of these stress-resistance pathways may be linked to late-life diseases. For example, worms with genetic variants leading to protein

aggregation and neurodegeneration, as in human Huntington disease, show neurological dysfunction that can be delayed, and in some cases prevented entirely, by augmentation of the FoxO-dependent stress-resistance pathways. Similarly, age-dependent increases in susceptibility to stress-induced cardiac arrhythmias in Drosophila can be significantly postponed by activation of FoxO-dependent protective pathways.

Figure 1-6 shows some of the evidence linking stress resistance to lifespan in worms, mice, and cells from longer-lived mammalian species. DR and at least some of the long-lived endocrine mutant stocks show elevated levels of enzymes with antioxidant action, heavy metal chelators, and intracellular chaperone proteins, and also have lower levels of oxidative damage to DNA, proteins, and lipids. Cells grown in tissue culture from long-lived Snell and Ames dwarf mutant mice, or from mice lacking GH receptor, are resistant to lethal injury caused by cadmium, peroxide, heat, a DNA alkylating agent, ultraviolet light, and paraquat (which induces mitochondrial damage by free radical generation). Mice prepared by CR or MR diets are resistant to liver damage induced by the oxidative hepatotoxin acetaminophen, and long-lived mutant mice are somewhat more resistant to death induced by paraquat injection. Stress resistance also seems to play a role in evolution of long-lived species. For example, cells from long-lived rodents and other mammals are resistant in culture to several forms of oxidative and nonoxidative damage, have high levels of an enzyme that protects mitochondria from oxidative injury, and high levels of molecular complexes that degrade damaged proteins. Cells from longer-lived species also employ a range of approaches, some involving control of telomere length and some unrelated to telomere biology, to diminish the likelihood of neoplastic transformation. This work suggests that variations in aging rate may be due in part to differences in stress-resistance pathways, but many questions remain unanswered.

FIGURE 1-6. Links between exceptional longevity and resistance to stress. (A) Skin-derived fibroblasts from long-lived mutant (red symbols, dw/dw, Snell dwarf) mice are resistant to the lethal effects of hydrogen peroxide, H2O2. Each symbol is an individual mouse, and the Y-axis shows the amount of H2O2 needed to kill 50% of the cells. (B) Skin-derived fibroblasts from long-lived species are relatively resistant to lethal injury induced by H2O2. Each symbol represents a different rodent or bat species with the indicated maximum lifespan. Species, left to right, are laboratory mouse, wild-caught mouse, rat, red squirrel, white-footed mouse, deer mouse, fox squirrel, porcupine, beaver, and little brown bat. LD50 is the amount of hydrogen peroxide that kills 50% of the cells. (C) Cells from long-lived rodent species are resistant to changes in oxidized proteins (“protein carbonyl” on Y-axis) induced by 1-h exposure to H2O2.

Each symbol is a different species, with the species’ lifespan indicated on the X-axis. (A, Adapted with permission from Murakami S, Salmon A, Miller RA. Multiplex stress resistance in cells from long-lived dwarf mice. FASEB J. 2003;17[11]:1565–1566; B, Reproduced with permission from Harper JM, Salmon AB, Leiser SF et al. Skin-derived fibroblasts from long- lived species are resistant to some, but not all, lethal stresses and to the mitochondrial inhibitor rotenone. Aging Cell. 2007;6[1]:1–13; C, Reproduced with permission from Pickering AM, Lehr M, Kohler WJ, et al. Fibroblasts from longer-lived species of primates, rodents, bats, carnivores, and birds resist protein damage. J Gerontol A Biol Sci Med Sci. 2015;70[7]:791– 799.)

A long-standing model posits that chronic accumulation of unrepaired damage to nuclear and/or mitochondrial DNA contributes to the effects of aging. ROS, generated via normal cellular metabolism, have been hypothesized to represent a major source of this damage. In support of this idea, DNA lesions, mutations, and aneuploid cells (cells with incorrect chromosomal number or rearranged chromosomes) accumulate with age in mammalian tissues. Because such events occur stochastically on a cell-by- cell basis, it has proven difficult to rigorously identify and quantitate such events. Aging leads, in mice and humans, to increased incidence of aneuploidy. Although evidence that accumulation of DNA damage contributes to aspects of aging other than neoplasia is currently modest, elevated levels of a protein involved in repair of DNA damage, SIRT6, can increase mouse lifespan in males and delay cancer and metabolic dysfunction. Further work in this and similar models may help to clarify the possible role of genome maintenance in aging and nonneoplastic diseases.

The role of ROS in inducing age-associated genetic damage, or in aging more generally, remains controversial. Resistance to many forms of stress, including oxidative injury, is a common feature of long-lived mutants, as described above. However, many mouse mutations that impair resistance to ROS damage have no detectable effect on lifespan and show no obvious acceleration of age-related pathology. Furthermore, administration of antioxidants to mice or people does not extend lifespan and may under some circumstances actually increase mortality. Conversely, for the most part mouse strains with increased activity of ROS defense systems show protection from specific toxins that cause oxidative injury, but do not show extended lifespan. The only current exception is a mouse strain overexpressing the antioxidant enzyme catalase in mitochondria. These animals show increased lifespan, and, by some measures, improved health in old age.

The famous observation of Hayflick that human diploid fibroblasts cease to grow in culture after a limited number of population doublings sparked a line of experimentation that continues to yield important insights into the molecular control of cell growth, differentiation, and neoplastic transformation. Human fibroblasts placed in tissue culture will divide until approximately 50 cell doublings have occurred, after which the remaining

cells survive indefinitely in a healthy but nondividing state. In the 1970s and 1980s, this “clonal senescence” model seemed to be an attractive approach to study the genetics and cell biology of aging. It is now clear that growth cessation of continuously passaged human fibroblasts is caused principally by the progressive loss of telomeric DNA at the ends of each chromosome at each mitosis, which occurs in cells that lack a specialized enzyme complex called telomerase. Critically shortened telomeres induce a DNA damage response in the cell, leading to senescence or cell death. Short telomeres can influence intracellular signaling to hamper mitochondrial function, thereby impairing cellular metabolism, suggesting that damaged telomeres might exert effects even in tissues such as the liver that are largely postmitotic.

Telomeres and cancer (also see Chapter 82) Telomere-dependent clonal senescence clearly plays a critical role in the protection of humans from many forms of cancer. Telomerase is turned on, and telomere attrition prevented, in approximately 90% of malignant tumors in humans. Genomic sequencing efforts have revealed that individuals with mutations that chronically elevate telomerase activity, or increase the accessibility of telomeres to telomerase, are at increased risk for a variety of cancers.

Studies of the role of telomeres and telomerase in the biology of aging in mice have produced controversial findings. Mice have much longer telomeres than humans, but live much shorter lives. The rate at which telomeres shorten, however, is more rapid in mice than in humans, and mouse strains engineered to have elevated telomerase show increased cancer rates, consistent with a role for telomere length as a contributor to malignancy in mice, as in humans. Paradoxically, elevated telomerase function may improve some aspects of health in mice carrying other alleles that block many forms of neoplasia, though with no effect on maximum lifespan, a provocative observation worth further exploration. As indicated in Figure 1- 7, telomere erosion can, in different settings, lead to cellular senescence, or to changes in cell properties related to DNA damage, genomic instability, or neoplastic transformation. The potential role of these changes in late-life human disease is an area of active investigation. Genetic disruption of telomerase can also produce lines of mice with shortened telomeres. These mice are short-lived, but the spectrum of pathology, featuring skin ulceration, infertility, increased frequencies of specific forms of neoplasia, and frequently lethal gastrointestinal lesions, does not closely resemble the pattern of illnesses seen in normal aging mice or humans. Thus telomere

attrition, except for its major role in oncogenesis, does not seem likely to represent a major contributor to aging in rodents.

FIGURE 1-7. Two possible pathways by which telomere shortening can affect aging and diseases. The distal tips of mammalian chromosomes are “capped” by numerous copies of a hexanucleotide repeat (TTAGGG, designated in red). During serial cell division, or in response to genomic insults such as reactive oxygen species (ROS), telomeres progressively shorten.

Pathway 1 (se nescence). When they reach a critical threshold of attrition, loss of telomere binding proteins and telomere unfolding (“uncapping”) occurs, provoking a DNA damage response and leading to permanent cell cycle arrest (ie, senescence). Critically shortened telomeres can also cause mitochondrial dysfunction in vulnerable tissue types like the liver. Telomere uncapping and senescence can promote age-related pathologies such as bone marrow (BM) failure, pulmonary fibrosis, atherosclerosis, and hepatic cirrhosis. Pathway 2 (ne oplasia). In contrast, in cells that lack checkpoint control proteins like p53, shortened telomeres can provoke genomic instability, such as chromosomal end-to-end fusions, eventually culminating in neoplastic transformation. In stem cells and most cancer cells, telomerase is expressed and opposes telomere shortening by adding telomeric repeats back to the ends of chromosomes, thereby stabilizing telomere length. (Reproduced with permission form David Lombard.)

Senescent Cells Early work based on histologic assays suggested that senescent cells were rare (< 0.1%), even in biopsies from very old donors, although new methods for detecting other aspects of the senescent phenotype have led to upward revisions of this estimate. Senescent cells in vitro express a suite of secreted enzymes and inflammatory cytokines (not produced by dividing

fibroblasts), which may facilitate the growth of cancer cells and could in principle contribute to other aspects of aging at the tissue or organ level. The p16/INK4a protein serves to maintain a balance between senescence and oncogenic transformation. P16 is induced as part of the process during which cellular senescence halts cell proliferation. An increase in levels of P16 is observed in many tissues of aging mice, but particularly in stem cells, suggesting that senescent stem cells may indeed accumulate as a consequence of normal aging and may represent an evolved mechanism to prevent early- life neoplasia. P16 accumulation leads to diminished stem cell function in the aging bone marrow, brain, and pancreas. Mice engineered to have reduced levels of p16 retain stem cell activities at ages at which these cells proliferate poorly in normal animals, though these mice are somewhat more cancer-prone than normal controls. In humans, genetic polymorphisms near the p16/INK4a gene have been linked to age-associated conditions such as type 2 diabetes, coronary artery disease, and frailty. Interventions that prevent age-related induction of p16 might be an attractive approach to diminishing many forms of late-life illness in parallel, if the intervention did not simultaneously increase cancer risk.

Several research groups have developed genetic methods to delete senescent cells from adult mice, and there is current interest in the possible therapeutic potential of pharmacologically targeting senescent cells.

However, thus far there is little evidence for beneficial effects of these drugs, termed senolytics, in humans and little data on possible negative effects of such treatment. A series of ongoing clinical trials will evaluate the possible efficacy of senolytic drugs in the context of many age-associated diseases in humans, including osteoarthritis, Alzheimer disease, and others.

Complementing the mechanisms of aging discussed earlier, there are many more engineered mouse strains for which increased longevity has been reported in at least one laboratory. For some mutants, lifespan extension is sex-specific, as with SIRT6 overexpression, which increases male longevity specifically. In other cases, for example, the Ames and Snell dwarf strains, extended lifespan is observed in both sexes. Long-lived mouse mutants often show protection against important classes of age-associated pathologies, such as cancer, kidney disease, cataracts, immune failure, and glucose intolerance. This finding underscores the close connection between aging and

age-associated disease. As noted previously, several of these long-lived mutants show reduced GH signaling, typically with lower IGF-1 levels, and some also feature increased insulin sensitivity or alterations in insulin responses by specific cell types. Other mutants show impaired mTOR function or reduced activity of TOR’s downstream effectors, although these changes are often seen in one sex only, and typically produce less increase in lifespan than alterations in GH and IGF-1 signals. Other long-lived genetically engineered mouse strains highlight particular cellular functions that are important for longevity, such as genome integrity. For example, mice overexpressing the BUBR1 mitotic checkpoint protein show improved maintenance of the proper chromosomal number (euploidy) during age, along with protection from cancer, and extended longevity. Similarly, mice overexpressing the ATG5 protein show increased levels of autophagy, a cellular process for recycling damaged proteins and organelles, and increased lifespan. As a cautionary note, the majority of these studies have been performed in one laboratory, mostly in a single mouse strain. It will be important to replicate such studies in different genetic backgrounds and in multiple laboratories, to see whether the findings are reproducible and robust. Mutations that produce a specific form of pathology on one mouse strain often have no effect, or even the opposite effect, on other backgrounds, highlighting the dangers of forming general conclusions from work on a single inbred stock.

More work is needed to determine to what extent these mutations influence common pathways, to see whether they do or do not influence aging through the same mechanism. It is possible, for example, that some of these mutations diminish risk of cancer, a common cause of death in many inbred mouse strains, without effect on any other age-dependent trait, while others may modulate the effects of aging on multiple organ systems, thus diminishing both neoplastic and nonneoplastic diseases, lethal and nonlethal. In this regard, it will be useful to determine how these pathways may intersect with the DR response. In invertebrates, genetic studies have revealed that reduced mTOR signaling appears to overlap mechanistically with the response to DR. Analogous studies of DR have given ambiguous results: DR enhances lifespan effects in the Ames dwarf mouse, but has no such effect when administered to long-lived GHR KO mice. Some proteins may be required only for specific aspects of the response to DR, but dispensable for others.

insulin sensitivity that occurs during DR, but dispensable for many other DR- associated effects.

As mentioned earlier, diminution of GH or IGF-1 levels can create mice that are long-lived compared to controls. Similarly, mouse stocks bred by selection for slow early-life growth trajectory are smaller than controls and also longer-lived. There is also highly suggestive evidence for a similar relationship between IGF-1, body size, and lifespan in dogs and horses. For dogs, small-size breeds have greater longevity than large breeds, and there is a strong relationship between body size and life expectancy among mixed- breed dogs as well (Figure 1-8). Pony breeds of horses are also substantially longer-lived than horses of full-sized breeds. The relationship between body size and life expectancy in humans is complicated by the strong effects of socioeconomic status on both endpoints; wealthier people tend to be both taller and longer-lived than poor people. On the whole, tall stature is associated with lower mortality risks from cardiovascular diseases, which are a major cause of mortality in developed countries. In contrast, a remarkably consistent set of studies (Table 1-1) show that tall stature is associated with higher mortality risk from a wide range of neoplastic diseases. There is also limited data that centenarians, on average, were shorter as mature adults than those who do not attain centenarian status. Testing the idea that short midlife stature is associated with delayed or decelerated aging in humans will depend on measuring a wide range of age- dependent traits, rather than merely lifespan, on large populations of middle- aged people. Individuals with a genetic abnormality in GH receptor (“Laron dwarf mutation”) in an Ecuadorian community had very low serum levels of IGF-1 and IGF-2, and were much less likely than control subjects to die of cancer or to be diagnosed with adult-onset diabetes, findings consistent with the low age-adjusted cancer incidence and excellent insulin sensitivity of the corresponding long-lived, mutant mouse stock.

FIGURE 1-8. Longevity, size, and insulin-like growth factor 1 (IGF-1) levels among breeds of purebred dogs. Left panel (A) shows mean breed lifespan as a function of mean breed weight for each of 16 breeds of dogs; three breeds are indicated by arrows. Right panel (B) shows mean plasma IGF-1 levels as a function of body mass in eight breeds of purebred dogs. (A, Data from Li Y, Deeb B, Pendergrass W, et al. Cellular proliferative capacity and life span in small and large dogs. J Gerontol A Biol Sci Med Sci. 1996;51[6]:B403–B408; B, Reproduced with permission from Masoro EJ, Austad SN, eds. Handbook of the Biology of Aging, 6th ed. New York, NY: Academic Press; 2006.)

TABLE 1-1 ¦ POPULATION-BASED ASSOCIATION BETWEEN SHORT STATURE AND LOWER MORTALITY RISK FOR MULTIPLE NEOPLASTIC DISEASES

Integration of findings from invertebrates (including yeast cells), rodents, and cultured human cells has substantially enhanced understanding of the molecular pathogenesis of many diseases and continues to provide the driving engine for experimental therapeutics leading to clinical trials. A similar strategy focusing on pathways that regulate the aging process, and through altered rates of aging, could lead to the coordinated postponement of

the wide array of age-dependent diseases. Thus, pathways that clearly deserve deeper scrutiny have been delineated, usually because investigations in invertebrates, or, more rarely, mice, have revealed that genetic or chemical alteration of the target molecules can slow aging, preserve health, and extend maximal lifespan. Elucidation of the links between these biochemical pathways and hormonal signals, neoplastic transformation, stem cell homeostasis, and the balance between cell growth and cell death is likely to provide both rationale and direction for translational work aimed at slowing the aging process and retarding age-related disease and dysfunction.

Many of these pathways are interconnected, either within cells or through neuroendocrine connections, often making it difficult to draw simple, unidirectional maps discriminating causes from effects. Making the leap from convenient invertebrate organisms to the added physiologic complexity of rodents and humans also poses major challenges. Figure 1-5 illustrates connections among many of the molecular targets and intercellular pathways, potentially involved in the control of aging rate in mammals, which have attracted experimental attention and continue to be sources of controversy and new ideas. None of these has yet been proven to be a central regulator of aging and multiple age-related illnesses; none of those shown has yet been ruled out. Research in the coming decade should expand the list of interesting candidates, refine our knowledge of how these molecules control one another within the cell, and start to delineate the specific cell types, and tissues, through which these pathways influence aging rate and age-related diseases in mammals.

Seminal discoveries of aging regulatory mechanisms in simple model systems repeatedly turn out to be evolutionarily conserved and applicable to mammals. Because of the time required to create mutant mice and their significantly longer lifespan, it normally takes 5 to 10 years for initial discoveries to be repeated in vertebrate systems. Nevertheless, it is worth pondering the importance and potential impact of ideas that are currently in the “pipeline,” two of which are mentioned here:

of cell- and tissue-specific control of aging as a major focus of mammalian studies in the coming years.

Characterizing genetic mutants with increased lifespan is one means to elucidate pathways important in regulating longevity. A different, complementary strategy is to identify small molecules that extend lifespan. Work in this direction is being carried out by a consortium of three laboratories, funded by the US National Institute on Aging as the Interventions Testing Program (ITP). The ITP consortium evaluates three to six new drugs or nutritional supplements each year for possible benefits to mouse lifespan, using a genetically heterogeneous mouse stock to diminish the chances of detecting, or missing, results that would apply only in mice carrying a single, potentially idiosyncratic, genotype. There is now evidence that at least four drugs—rapamycin, canagliflozin, acarbose, and 17-a- estradiol—can improve survival and increase maximal longevity in mice.

Rapamycin, an inhibitor of the intracellular enzyme mTOR, increases lifespan in both males and females, with increases as high as 26% at the highest dose so far tested. Acarbose, which slows the intestinal digestion of starches to sugars and thus blunts postprandial surges in blood glucose, increases male lifespan by 22%, and has smaller, though still significant, effects in females. Similarly, canagliflozin, a widely prescribed drug for diabetes that primarily inhibits glucose reabsorption by the kidney, extends the median lifespan of male mice by 14%, but had no benefit in females. 17- a-Estradiol, a nonfeminizing isoform of estrogen (17-ß-estradiol), increases lifespan of male mice by 19%, but does not extend lifespan in females.

Another agent, nordihydroguaiaretic acid (NDGA), which has both antioxidant and anti-inflammatory actions, improves lifespan of male mice only, and a significant survival benefit was also reported for male and female mice given food supplemented with high levels of the amino acid glycine.

Figure 1-9 illustrates lifespan extension in mice given rapamycin or acarbose, and shows the delay in several forms of midlife pathology in rapamycin-treated mice.

FIGURE 1-9. Increased lifespan and improved late-life health in mice treated with rapamycin (R, or Rapa) or acarbose (ACA). (A) Increased mean and maximal lifespan in female mice exposed to varying doses of rapamycin (4.7, 14, or 42 mg drug per kg food) from 9 months of age. (B) Four forms of age-related pathology seen in 22-month-old mice that are less frequent in mice treated with rapamycin. (C) Rapamycin treatment delays the effects of aging on the properties of an extracellular tissue, in this case elasticity of collagen fibers from the tail tendon.

(D) Extension of lifespan in male mice treated with acarbose (1000 mg per kg food) from 4 months of age. (A, Reproduced with permission from Miller RA, Harrison DE, Astle CM, et al. Rapamycin-mediated lifespan increase in mice is dose and sex dependent and metabolically distinct from dietary restriction. Aging Cell. 2014;13[3]:468–477; B & C, Reproduced with

permission from Wilkinson JE, Burmeister L, Brooks SV, et al. Rapamycin slows aging in mice, Aging Cell. 2012;11[4]:675–682; D, Reproduced with permission from Harrison DE, Strong R, Allison DB, et al. Acarbose, 17-a-estradiol, and nordihydroguaiaretic acid extend mouse lifespan preferentially in males. Aging Cell. 2014;13[2]:273–282.)

Studies of this kind can establish, as proof of principle, that drugs added to food can increase mammalian lifespan. From this perspective they help support the evidence from studies of diets and single-gene mutations that the aging process in mammals can be delayed or decelerated sufficiently to have an important effect on survival, and overall health, at older ages. Figure 1-10 compares the extent of lifespan extension achieved, so far, in drug-treated mice, in parallel to effects produced by single-gene mutations, both spontaneous and targeted.

FIGURE 1-10. Selected reports for mouse lifespan extension mediated by mutations or drugs. Colors indicate functional groupings: pink for alteration of GH (growth hormone), insulin, or IGF- 1 (insulin-like growth factor 1), green for mTOR (mammalian target of rapamycin), yellow for unknown or other pathways. (*) indicates confirming reports from at least one other laboratory group and/or in at least two independent cohorts. (?) indicates that substantially smaller results were obtained in another laboratory. Effects that were reported as “zero” are illustrated, as a convention, at -1 to allow the bar to be visible. BRASTO: brain-specific SIRT1-overexpressing; IRS1: insulin receptor substrate 1; KO: knockout; LST8: lethal with SEC13 protein 8; OE: overexpressor; PAPP-A: pregnancy-associated plasma protein A; s6K1: S6 kinase 1. (Reproduced with permission from David Lombard and Richard A. Miller.)

These studies point to specific drugs, and classes of drugs, that might deserve further, more intensive analysis, as tools to learn more about the biology of aging and late-life diseases. The benefits of rapamycin on lifespan seem to be equivalent whether the drug is initiated in young adult mice or in mice already more than half the age of median survival, suggesting that inhibition of TOR function may be beneficial even if started at relatively late ages. Moreover, this result hints that mTOR signaling may increase in older individuals and contribute to the degenerative effects of aging. Strikingly, pharmacologic mTOR inhibition in older adult humans improves responses to influenza vaccination, hinting that drugs identified as having beneficial effects on lifespan and late-life health in rodents may have similar effects in humans.

The striking acarbose and canagliflozin results should prompt additional studies of the role of transient glucose surges in the control of aging rate.

Although the effects of both drugs on peak glucose levels make them useful for the treatment of diabetes in humans, it is noteworthy that diabetes is quite rare in the mouse stock used by the ITP, and that most of the ITP mice die because of some form of neoplasia. More work will be needed to discover how acarbose and canagliflozin slow cancer progression, whether they slow the pace of other age-related changes, such as cataracts, sarcopenia, immunosenescence, and cognitive decline, and why the lifespan benefit is so much stronger in male than in female mice. The male-specific benefits of 17- a-estradiol will prompt new work on the routes by which steroids can modulate cancer and other late-life diseases. Both acarbose and 17-a- estradiol produce significant lifespan and functional benefits even when started in midlife; parallel studies on canagliflozin are now under way.

Obstacles related to translation of these experimental results into clinical trials are discussed later.

Attempts to find genetic variations that influence aging in humans have been plagued with practical and conceptual problems. For one thing, heritability calculations show that only 15% to 20% of the variation in lifespan among humans can be attributed to genetic factors. However, the magnitude of the influence of genetics on longevity may rise with increasing age. Furthermore,

an unknown but potentially large fraction of this genetic variation probably reflects genetic variants that influence susceptibility to diseases of childhood, infectious agents, and specific common illnesses of old age. For example, genetic variants that cause Huntington disease or type 1 diabetes or that triple the normal risk of myocardial infarction by the age of 50 would all contribute to the measured heritability of lifespan but do so by altering mortality risks from a specific form of illness rather than by alteration of aging with its effects on multiple late-life traits. Thus, genetic variants that mold lifespan by effects on aging per se, if they exist at all, are likely to influence only a small fraction of variation in how long people live.

Formal analyses of the genetics of human aging have so far relied mostly on candidate gene approaches, in which long-lived and control populations are evaluated for variations at one or a small number of genetic loci selected on theoretical grounds as most likely to be involved in aging or disease processes. In such studies, polymorphisms near the FOXO3A, APOE, and

SIRT3 genes have been identified as enriched in long-lived individuals. The FOXO3A transcription factor is a FoxO protein, modulated by insulin and IGFs. Apolipoprotein E (APOE) polymorphisms are well-known to affect the risk of developing cardiovascular disease and Alzheimer dementia. SIRT3 is a sirtuin family member; this protein resides in mitochondria, where it regulates multiple metabolic processes. An alternative approach is whole genome screening of large populations for association of longevity with hundreds of thousands of genetic variants. Thus far, only APOE polymorphisms have been identified in multiple studies, while other potential genetic associations have proven difficult to replicate. There are several possible explanations for these discrepancies, including lack of a consistent definition of longevity between studies, different ethnic backgrounds of study populations, inadequate sample sizes leading to insufficient statistical power, differing living conditions, lack of ideal control populations, and other confounding factors.

A major problem with all these approaches, from the perspective of biological gerontology, is the lack of a defensible phenotype: a measure of aging better than lifespan. There are now several dozen reports of candidate loci at which particular alleles are overrepresented among centenarians or near-centenarians, and advocates of this strategy hope that among this collection are some loci that control aging rate. But skeptics note that alleles that increase risk of cardiac disease, Alzheimer disease, stroke, various

common forms of cancer, or severe osteoporosis are likely to have contributed to disease and death before the age of 90 or 100, and thus to have been eliminated or greatly reduced among very old people. Thus, it should be assumed that a collection of genetic loci whose frequency discriminates very old people from others of the same birth cohort will include many genes with influence over common forms of lethal illnesses rather than genes that modulate aging per se. This problem is not one that can be solved by technological innovation or larger numbers of tested subjects; it requires development of a phenotype that provides more information about health in old age than merely a record of the age at death. For example, a genetic allele that identified, among 70-year-old people, those most likely to have excellent eyesight and hearing, no history of cancer, angina, diabetes, or arthritis, above-average responses to vaccination, and retention of baseline levels of cognition and muscle strength would be a much stronger candidate for an authentic “antiaging” gene than one that predicted survival to the age of 100.

There are a small number of rare inherited diseases, of which Werner syndrome (WS) and Hutchinson-Gilford syndrome (HGPS) are the most celebrated, that have been mooted as possible examples of “accelerated” aging. Some of the physical features and symptoms of these diseases do resemble, at least superficially, some of the changes that typically affect older people, including changes in skin, connective tissues, and the vasculature. HGPS, sometimes called “progeria,” is now known to be caused in most patients by mutations in the gene encoding Lamin A, a component of the nuclear membrane. WS patients usually have mutations in an enzyme (WRN) that functions as a DNA helicase (unwinding coiled DNA) and as an endonuclease.

It is debatable whether either of these diseases provides strong clues about the molecular or cellular basis for age-related changes in normal individuals. WS patients do resemble older people in some ways: They frequently suffer from cataracts and premature graying of the hair, and by their early thirties often develop osteoporosis, diabetes, and atherosclerosis. On the other hand, many features of normal aging are not seen in WS patients and many features of WS are not seen in normal old individuals. WS patients, for example, do not show signs of Alzheimer disease or other amyloidoses,

hypertension, or immune failure. Mesenchymal tumors, which are rare in normal people, are about 100-fold more frequent in WS patients, but the epithelial and hematopoietic tumors characteristic of normal aging are far less common in these individuals than in normal old people. Furthermore, WS patients exhibit many features that are not seen in normal aging, including subcutaneous calcifications, altered fat distribution, vocal changes, flat feet, malleolar ulcerations, high levels of urinary hyaluronic acid, and a number of other phenotypes not seen commonly in older adults. It seems plausible that the loss of the WRN mutation, perhaps through alteration of cells responsible for connective tissue maintenance, induces multiorgan failure through processes distinct from the changes that impair some of the same organs in normal aging.

The central rationale for biological gerontology is the hope that discoveries in this field will lead to innovations in preventive medicine. Mice subject to DR, or with genetic manipulations that increase lifespan, show protection from a wide array of diverse age-associated pathologies, and there is growing evidence that multiple signs of aging occur more slowly in mice treated with rapamycin. An authentic antiaging drug that produced the same demographic changes in humans seen in rodents on DR or MR diets would yield about 10-fold greater improvement in mean life expectancy than would the complete elimination of cancer or of myocardial infarction (Figure 1-11). A detailed understanding of the molecular pathways that lead to coordinated stress resistance in cells of dwarf mice, or of the adjustments that render DR rats resistant to autoimmune, neoplastic, and degenerative diseases, or of the evolutionary changes that permit large animals to survive cancer-free and cataract-free for many decades should in principle suggest avenues to preventive medical care that could dramatically postpone disability and lethal illnesses.

FIGURE 1-11. Theoretical remaining life expectancy of a 50-year-old White woman in the United States under a variety of demographic assumptions. The top bar shows remaining life expectancy with disease-specific mortality rates that prevailed in 1985. The four middle bars show projected life expectancy under the assumption that mortality risks for the indicated diseases were in fact zero. The bottom line shows projected longevity if it were possible to retard human aging to the same degree that is obtained in the typical study of caloric restriction in rats or mice. (Data from Olshansky SJ, Carnes BA, Cassel C. In search of Methuselah: estimating the upper limits to human longevity. Science. 1990;250[4981]:634–640.)

But the pathway connecting discovery in this area of basic science to intervention is strewn with obstacles, some scientific, and others political, economic, and legal. Testing directly whether an agent that dramatically increases healthy longevity in other species is able to safely extend human lifespan would require vast resources and treatment of young or middle-aged adult subjects for many decades. Neither pharmaceutical firms nor governmental agencies are likely to be able to support such an ambitious long-term undertaking. Nor are many scientists eager to devote their careers to an experiment whose conclusions are unlikely to emerge until the time of their own retirement. A hypothetical agent that is active in those already old could, in principle, be tested with a relative short follow-up, that is, over a period of 5 to 10 years. Such agents might be evaluated in the context of discrete age-associated pathologies or well-defined markers of the rate of aging, rather than in lifespan extension. In this regard, the demonstration that an mTOR inhibitor enhances the response to the influenza vaccine in older individuals represents a significant step forward. Many of the interventions tested so far in mice, including rapamycin, acarbose, 17-a-estradiol, and a

diet low in methionine, lead to lifespan extension even when initiated in mice already well into the second third of their lifespan, and they provide some hope that interventions that slow aging could in principle be effective when administered to middle-aged people as well. A current clinical trial will test the ability of metformin to inhibit development of multiple age-associated diseases (Alzheimer or other dementias, cancer, heart disease, and diabetes) in healthy older individuals.

Introduction of authentic antiaging compounds into the practice of health care may involve relatively unconventional pathways. Some people appear willing to consume compounds and mixtures, labeled as “nutritional supplements” to render them exempt from laws that govern prescription and nonprescription drugs, which are purported to oppose the effects of aging.

Thus far, there is no evidence that any of the agents so touted, including melatonin, dehydroepiandrosterone, resveratrol, homeopathic remedies, and many others, can retard, delay, or reverse aging in humans. Intervention studies in pet dogs that provide evidence that a drug extended healthy lifespan could help to shape the discussion about ways to introduce such interventions into human preventive medicine, and one such study, using rapamycin, has already been initiated. If a promising agent can be shown through typical short-term clinical tests to be useful for the treatment or prevention of a specific disease or condition, further study of broader disease prevention and enhanced survival may ensue.

Serious research into the basic biology of aging and proposed translational research to turn gerontological discoveries into antiaging medicines have long been hobbled by pessimism, specifically the assumption that aging is immutable, and by stigma, arising from claims made for allegedly effective antiaging potions promoted unscrupulously for commercial gain. For these reasons, many political and scientific leaders have been understandably shy of lending support for research efforts whose goal is to develop antiaging interventions for human use. Journalists, who are often aware of promising discoveries in biological gerontology, are nonetheless often drawn ineluctably toward promotion of extreme claims, which, while entertaining, go well beyond scientific evidence and thus further impair the credibility of

the antiaging research enterprise. Although several decades of evidence has now clearly refuted the commonly held assumption that the aging process is too complex or too stable to be altered, the attitudes and expectations of opinion leaders and the lay public greatly undermine and complicate efforts to attract support for this area of research.

A related concern is often posed as a question of ethics: If the goal of antiaging research is to help keep people alive and healthy for several decades beyond their current “natural” lifespan, would not realization of this goal greatly complicate efforts to solve the current set of Malthusian dilemmas? In a world where resource depletion, food and water shortages, and environmental degradation already consign billions to great suffering, would not methods that delay aging and death lead to unacceptable exacerbations of these and related problems? Arguments along these lines are often influenced by the unstated assumption that old people are typically ill, unhappy, and unproductive, and by a desire to avoid creating a society in which an ever-increasing proportion of the population has the problems that can afflict people at the very end of life.

The concern that development of antiaging medicines would be unethical is easy to refute. Most of modern medical research is designed to help prevent or treat diseases with a high risk of mortality and thus to increase the likelihood that patients will enjoy additional years or decades of good health. Efforts to develop vaccines for COVID-19, or to eradicate residual tumor burden by adjuvant chemotherapy, or to correct arrhythmias, or to alleviate the symptoms of diabetes or gallstones are all designed to allow patients to remain healthy and active as long as possible. These research efforts are appropriately considered ethical and indeed heroic, even though patients so treated are quite likely to encounter additional illnesses, often associated with suffering, at later ages. A similar motivation and justification underlies translational research in biological gerontology. Clearly, there is no pressing need for agents that merely prolong life in people who are in the final stages of a dementing illness or nearing death in great pain, and developing drugs that extend lifespan without improvements in health would not be an attractive goal. Fortunately, each of the dietary, pharmacological, and genetic manipulations shown in rodent models to extend longevity does so by an increase in the length of healthy lifespan; postponement of death goes hand in hand (and is almost certainly caused by) postponement of a very wide range of diseases and forms of disabilities.

A society in which many people remain active and productive at ages of 80 to 100 or so would indeed require economic adjustments and alterations of assumptions about retirement ages and family structure, just as adjustments of this kind have been required as societies have experienced reductions in infant and childhood mortality that greatly increase the proportion of newborns that reach the ages of 20 to 50. Such adjustments are not trivial, but such fears have not raised concerns about the ethical merit of insulin therapy, vaccination programs, smoking cessation clinics, or adjuvant chemotherapy. Thus, success in antiaging research should be considered highly desirable rather than pernicious.

Preparation of this chapter was supported by NIH grants AG022303, AG023122, and AG024824 (RAM), R01GM101171 and R21ES032305 (DL), and R01AG030593, R01AG043972, and R01AG023166 (SP), and by

a grant from the Glenn Foundation for Medical Research. We appreciate the willingness of several colleagues, mentioned in the figure legends, to share with us some of their own data for inclusion in this chapter.

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The aging of a population reflects the health of the population. The changes in life expectancy over the past century have varied tremendously throughout the world, with losses in some regions due to the epidemic of human immunodeficiency virus (HIV) and war, and gains in life expectancy in politically stable countries with low infant mortality. Improvements in the control of infectious disease, largely through sanitation but also through the development of antimicrobials and vaccines, account for the majority of gain in life expectancy worldwide. As a result, many developing countries have transitioned to having a larger proportion of the population reaching old age within one or two generations. This shift toward greater longevity has been accompanied by higher rates of chronic disease and a need for more chronic health care. The simultaneous decline in birth rates has left a smaller proportion of young to old. This change in the dependency ratio makes the prevention of disability in old age a public health priority.

Older adults develop multiple chronic health conditions that contribute to physical and cognitive decline. Many of these conditions are driven by age itself, with age representing the sum of time-dependent exposures and the biologic response to damage. This damage is both extrinsic, from behavioral and environmental insults, and intrinsic due to imperfect cell maintenance and repair. With time, these processes lead to distinct chronic conditions with hypertension, degenerative arthritis, coronary artery disease, cancer, and dementia among the most common. Though patterns of onset and duration vary widely, multimorbidity drives much of the disability that occurs in late life. Recent epidemiologic research regarding how chronic conditions

combine and interact suggests that multimorbidity is an informative outcome for clinical trials of therapies designed to improve overall health in older adults.

In the twentieth and twenty-first centuries, gains in life expectancy have resulted from reductions in infant mortality and prevention of chronic diseases, especially cardiovascular disease and chronic lung disease, which is largely related to a decline in smoking. More recently, gains have been made after age 65, with better survival after the onset of chronic illness.

While many projections continue to show continued large increases in the numbers and proportions of older adults in countries around the world, the current pandemic of COVID-19 is already showing an impact. The earliest outbreaks in China, Italy, and the United States were most prominent in the oldest and frailest, especially those living in congregate setting such as nursing homes. Since longevity projections are based on mortality rates across the lifespan and since children and young adults have not been greatly impacted by COVID-19 mortality, we might anticipate that the gains in life expectancy will be slowed or reversed in the oldest old. However, current threats to education and employment have the potential to adversely impact health across the lifespan, and particularly in marginalized populations such as racial and ethnic minorities. Therefore, our discussion of trends in the numbers and survival of older adults must be viewed with the changing environment in mind.

threatened by counterpoising trends in obesity, health inequities, and the current COVID-19 pandemic.

In this chapter, we will review the current estimates for population aging and demography including the leading causes of death in older adults and the role of birth cohort and period effects in interpreting aging trends. We will address rates and risk factors for the most common chronic conditions as well as patterns of multimorbidity and shared risk factors. We will also review trends in disability, including physical and cognitive disability and several novel risk factors under study that may tell us about the epidemiology of the biology of aging itself.

Table 2-1 summarizes the actual and projected aging population of the United States over 150 years. At the turn of the twentieth century, adults aged 65 and older made up only 4.1% of the population, and this percentage tripled over the following 100 years to 12% at the turn of the millennium. The US Census Bureau projects this number will continue growing to over 20% by the year 2050. The numbers of oldest old adults, aged 85 and older, are growing at an even more dramatic rate. In the twentieth century, the number of adults aged 65 and older grew 11-fold, whereas the number of adults aged 85 and older grew 42-fold. The number of oldest old adults is projected to continue to grow and is projected to comprise over a fifth of the population age 65 and older. This aging of the population has important implications for family structures, the labor market, economy, medicine, and long-term care;

moreover, it ensures that older adults will be an increasingly influential segment of our population.

TABLE 2-1 ¦ ACTUAL AND PROJECTED GROWTH OF THE OLDER US POPULATION, 1900 TO 2050 (MILLIONS)

The aging of the population is a global phenomenon. Figure 2-1 illustrates the increase in the percentage of the population age 65 and older from 2010 to 2050 in all six regions of the world. The highest current and projected percentage of 65 and older adults is in Europe, with North America, Latin America/Caribbean, Asia, and Oceania not far behind. Africa has the lowest percentage of older adults, but this number is expected to nearly double from 2010 to 2050. Latin America/Caribbean and Asia also have high projected growth in the population age 65 and older; the percentage is expected to double from 2010 to 2050. Nine of the top 10 countries with the oldest populations are in Europe, although Japan tops the list. The percentage of the population that is aged 65 and older depends on both the change in life expectancy as well as the fertility rate. Life expectancy is increasing globally, and fertility rates are falling. Older adults are living longer and thus comprise a larger proportion of the population. Dropping fertility rates can also lead to a relatively greater proportion of older adults by decreasing the number of children entering the population. Europe has the lowest fertility rate of 1.6 children per woman, whereas Africa has the highest fertility rate of 4.7 children per woman.

FIGURE 2-1. Percentage of population age 65 and older in 2010 and projected for 2030 and 2050. (Data from US Census Bureau, International Data Base.)

Survival curves are commonly used to illustrate the proportion of a population that survives to specified ages. Figure 2-2 illustrates the changes in the survival curves in the United States since 1900. In 1900, the steep drop in the survival curve between birth and 5 years demonstrates the high burden of infant and early-childhood mortality. In this era, there was a modest slope of the proportion surviving across adulthood, with less than half of the population reaching age 65. By the mid-twentieth century, there had already been substantial improvements in early life mortality, and survival increased for those in mid-life due to sanitation and availability of antimicrobials and vaccines. Although the greatest gains in the proportion surviving were for those in mid-life, there were gains in the proportion surviving across the age- spectrum. Survival continued to increase for older adults through the latter half of the twentieth century and into the twenty-first century. These gains have been largely due to improved therapies for people with chronic conditions, such as cardiovascular disease and cancer, as well as reductions in some risk factors, such as smoking. Notably, these gains extended even to those above 80 or even 90 years. The change in the shape of the survival curve over the past century is referred to as the rectangularization of the survival curve and some have proposed that this will continue until full rectangularization is achieved. However, some question this outcome. There

are adverse temporal trends, such as the increasing obesity epidemic, that threaten the gains in life expectancy, as well as emerging risk factors such as the COVID-19 pandemic.

FIGURE 2-2. Survival curves for US population. (Data from Arias E. United States life tables, 2009. Natl Vital Stat Rep. 2014;62[7]:1–63.)

While the above survival curves are based on observed data, life tables project the life expectancy for a given birth cohort. These projections assume that period-specific death rates apply to the future. While there may be deviations from this assumption, this method evaluates the long-range implications of the contemporary death rates. Table 2-2 illustrates the life expectancy projections at birth, 65, 75, and 85 years for men and women, and across race and Hispanic ethnicity. Notably, the older age groups in 2017 have a higher expected age at death compared with those born in 2017. This is because survival to older age represents a selected group of individuals who are more likely to continue to survive. For example, those who are 85 years in 2017 represent a selected group who have already exceeded the median life expectancy for the population, so it is not surprising that this group represent a healthy survivor group with an additional life expectancy of another 5.9 years for men and 7 years for women. In developed countries,

women have a greater projected life expectancy than men. At any given age, including preconception, women have lower mortality rates than men. Many explanations for the female survival advantage have been proposed including genetics, hormones, lower rates of smoking and alcohol use, greater health- seeking behavior, differences in occupational hazards, and others. Also apparent in Table 2-2 are the striking disparities in life expectancy by race; non-Hispanic Black men born in 2017 are projected to live 4.5 fewer years than their non-Hispanic White counterparts, and non-Hispanic Black women are projected to live 2.7 fewer years than non-Hispanic White women. These disparities reflect the unequal conditions in which people live, as well as the related racial disparities in chronic conditions. Hispanic adults have a longer life expectancy than non-Hispanic White and non-Hispanic Black populations. Various hypotheses have been proposed to explain this difference, commonly referred to as the Hispanic paradox. The most common potential explanations are (1) the healthy migrant effect, which suggests that Hispanic immigrants are in better health compared with their non-migrating peers; (2) the “salmon effect”, which posits that US residents of Hispanic origin may return to their birth country to die or when ill; and (3) differences in culture, including family structure, lifestyle behaviors, and social networks.

TABLE 2-2 ¦ LIFE EXPECTANCY IN 2017 (YEARS)

Exceptional longevity has been of interest in both the scientific and lay communities. Scientists have studied extreme longevity to gain insight into mechanisms of healthy aging and survival. Several centenarian studies have emerged across the world in parallel to a growing prevalence of people living to at least 100. When the New England Centenarian Study began in 1994, the estimated prevalence was one centenarian per 10,000 people; in 2012, this prevalence had doubled to 1 in 5000. This means that most

geriatricians will encounter centenarians in their practice. However despite this interest from the popular and scientific communities, little is known about the factors that predict survival to very old age as well as determinants of morbidity, disability, and mortality among the very old.

Scientists have long been interested in areas of the world where people appear to live longer than average, first termed “Blue Zones” by Dan Buettner in a 2005 National Geographic cover story. Some have proposed that a lack of validated birth certificates could play a primary role in apparently longer life expectancy. However, certain regions, such as Sardinia, Italy, have verified records and can confirm that residents live among the longest in the world. Hypotheses behind these concentrated geographic areas of long life expectancy include engagement in moderate physical activity as a part of life, plant-based diet, social engagement, a focus on family, and life purpose. However, there is currently no validated explanation about why centenarians are concentrated in such geographic areas.

The New England Centenarian Study has reported that siblings of centenarians have between 8 and 17 times the likelihood of living to 100 compared with others from the same birth cohort. Based on these estimates the heritability of extreme longevity to 100 years is expected to be between

0.33 and 0.48. Notably, this is larger than the estimates of survival to the mid-80s. Apolipoprotein E (APOE) and forkhead box O-3 (FOXO3) have polymorphisms that have been consistently shown to have associations with extreme longevity.

In 1980, Jim Fries proposed the “compression of morbidity” hypothesis that posits that as life expectancy increases, the years lived free of morbidity and disability (often termed the health span) will increase. Although there is substantial debate on whether we are observing the compression of morbidity in the general population, the evidence points toward a compression of morbidity as one reaches the limits of the human lifespan.

For example, the majority of centenarians do not experience disability until their 90s, although a substantial proportion accumulate one or more chronic condition. However, supercentenarians, those reaching age 105 or older, have a marked decrease in disability and disease compared with those who die at younger ages. Previous studies that found no evidence of compression

of morbidity may have been evaluating individuals who did not survive long enough to display this phenomenon.

The difference in life expectancy based on year of birth, highlights an important epidemiologic phenomenon known as cohort effects, where people have some common experience based on their year of birth, or another shared temporal experience. This is to be distinguished from age effects, which are effects common to people of a given age. Another time effect is known as period effects, in which people share some common effect due to the occurrence of an event defined by chronologic time. These three effects— age, period, and cohort effects—confound one another and can be difficult to disentangle in epidemiologic studies.

Conceptual differences in age, period, and cohort effects are illustrated in Figure 2-3. In this figure, three birth cohorts are illustrated: those born in 1930, 1940, and 1950. The first panel demonstrates pure age effects—the event rate of some disease increases with age. Age effects are familiar to many in health care, as the incidence of many conditions, such as cardiovascular disease, increases with age. The second panel illustrates pure period effect. Each birth cohort has a spike in event rates at the year 2020.

An example of a period effect is the 2020 SARS-CoV-2 pandemic, which increased the rate of pneumonia across persons in all three birth cohorts. The third panel illustrates pure cohort effects; those born in 1930 have the highest event rate, and the rate decreases with each decade of birth year. An example of a cohort effect is that children born during the Great Depression may have suffered from malnutrition, and be more likely to develop adult-onset diseases compared with those born in more prosperous times. One can observe how this would confound age effects, by evaluating the rate of disease in 2020 (indicated by X’s on the figure). The older age groups have higher disease rates in 2020, which could be inappropriately attributed to the aging process. These simplified figures illustrate what can be complex to disentangle with real world data, which generally contain a mix of age, period, and cohort effects.

In the past decade, the 65-and-older population has grown by 34% (14 million people), in large part due to the aging Baby Boomer generation, the first of whom turned 65 in 2011. Older adult women have and will continue to outnumber similarly aged men, though as shown in Figure 2-4 the sex differences in life expectancy will modestly narrow over the next four decades. For every 100 women aged at least 65, there will be 82 men in 2030 and 86 men in 2060. The sex ratio among centenarians will remain 2:5 (40 to 100) in favor of women for the next 40 years. These sex ratios reflect sex assigned at birth, and not gender identity.

FIGURE 2-4. Protected number of men living per 100 women at 65, 85, and 100 years and older. (Data from Vespa J, Medina L, Armstrong DM. Demographic Turning Points for the United States: Population Projections for 2020 to 2060. Current Population Reports, P25-1144. Washington DC: US Census Bureau; 2020.)

The majority of men, but not women, aged 65 and older are married. Among men aged 65 and older, 70% are married, 12% are divorced, and 12% are widowed. Among women aged 65 and older, 44% are married, 15% are divorced, and 34% are widowed. Women are more likely to outlive their husbands because of the longer life expectancy of women; 72% of women aged 85 and older are widowed. Living situation is determined by health, financial factors, and widowhood. The majority (68%) of adults aged 65 and older live with family, and about a quarter (26%) live alone.

The older population is becoming more diverse in the United States. Non- Hispanic White adults made up 77% of those aged at least 65 in 2017, but are expected to make up only 55% of older adults by 2060 as seen in Figure 2-5. All racial/ethnic groups are expected to increase proportional to non- Hispanic White older adults, with the greatest increases projected among Hispanic adults age 65 and older. Black and Hispanic populations tend to shoulder a disproportionate burden of morbidity and disability compared with their White counterparts. For example, among adults aged 65 and older, 46% of Black adults had a disability compared with 33% of Asian and 38% of White adults. Among those who reported Hispanic origin, 42% had a disability compared with 38% of those who were not Hispanic. The higher burden of poor health in these communities reflects the unequal conditions in which Black and Hispanic populations live. Only 7.2% of White adults aged

Americans. Among those who report Hispanic origin, 18% fall below the poverty line. Educational attainment follows similar patterning, with only 73%, 74%, and 52% of Asian, Black, and Hispanic adults age 65 and older reporting a high school education, compared with 89% of White older adults.

The growth of the older population has led to an increase in the non-working- age population (0–14 and 65 and older) relative to the working-age population (aged 15–64). The ratio of non-working-age to working-age people, which demographers term the dependency ratio, has grown from 49 in 2010 to 54 in 2019. Dependency ratios offer a unique perspective on the nation’s aging. However, this statistic provides limited insight into the economic repercussions, as many older adults remain in the labor force well past 65. Moreover, many older adults have accumulated financial assets and asset transfer may mitigate this dependency ratio. Among those 65 and older, 22% of men, and 14% of women remained in the labor force in 2016 in the United States. These numbers decreased with age; only 3.7% of men and 1.5% of women age 85 and older remained in the labor force.

Temporal trends demonstrate that the years spent working and in retirement have changed dramatically. Based on estimates from the Organization for Economic Cooperation and Development (OECD), in 1960, men in developed countries could expect to spend 46 years in the labor force and about 1 year in retirement. By 2005, years in the labor force had decreased to 36, whereas years in retirement had increased to 14. The striking increase in the number of years people can expect to live after retirement are primarily driven by the gains in life expectancy. There was a trend toward earlier retirement near the end of the twentieth century, although this trend has slowed or reversed in recent years.

Recent estimates from the National Vital Statistics Report (Table 2-3) have implications for primary, secondary, and tertiary disease prevention.

Approximately a third of all deaths in 2017 can be directly associated with chronic dysregulation of cardiovascular, renal, and endocrine systems.

Pneumonia, the lone infectious disease that causes death, includes bacterial, fungal, or viral diseases acquired in community or health care settings.

Furthermore, pneumonia has a higher fatality rate among those with conditions including chronic obstructive pulmonary disease; the resultant organ damage among pneumonia survivors may precipitate further life- threatening health events. The risk of nonintentional accidents and falls that result in death can be partially a consequence of sensory and functional

decline. Thus the leading causes of death have overlapping and underlying causal risk factors.

TABLE 2-3 ¦ LEADING CAUSES OF DEATH AMONG PERSONS 65 YEARS AND OLDER IN 2017

Notably, a quarter of older adult deaths could not be ascribed to a single cause. This highlights the challenges of mortality ascertainment among the segment of the population with the highest burden of chronic conditions.

Additionally, the all-other cause category includes deaths subject to social stigma, such as “diseases of despair”: alcohol-related liver disease, controlled substance overdose, and suicide. The rate of diseases of despair among adults aged 65 increased from 45 to 57 deaths per 100,000 from 2009 to 2019, according to Centers for Disease Control and Prevention data.

Mortality rates declined by 21% among all ages between 1935 and 2017. The reduction in death is even more pronounced among older adults. Among adults between 65 and 74 years, mortality rates were 60% lower in 2017 compared to the period of the Great Depression. Comparing people aged at least 85 over time reflects these gains in population health; though there is a higher absolute number of deaths among the oldest old, the mortality rate was 40% lower in 2017 than 1935.

The elevated prevalence of chronic conditions in older adults corresponds to the patterning of older adult mortality. As observed in Figure 2-6, the mortality rates increase for the leading causes of death with advancing age. As the most striking example, the estimated Alzheimer’s mortality is less than 1 per 100,000 among people younger than 65 and 350 per 100,000 among people between the ages of 80 and 84. The only leading cause not following a consistent age-gradient is death related to accidents.

Fatal accidents appear highest among people in their early to mid-80s and second highest among people in their mid to late 50s, with modest declines between the sixth and seventh decades. The most common type of accident also varies between the middle aged (vehicular) and the oldest old (falls).

FIGURE 2-6. Age-specific death rates for leading cause of death in the older population, United States, 2017. (Data from CDC/NCHS, National Vital Statistics System, Mortality 2017. National Center for Health Statistics; 2018. https://www.cdc.gov/nchs/data/dvs/lcwk/lcwk1_hr_2017-a.pdf .)

Figure 2-7 illustrates how cancer mortality rates peaked among the oldest old of both sexes at the turn of the twenty-first century. Men were disproportionately affected. In 1990, there were more than 500 cancer- related deaths per million men among both the 75 to 84 and 85+ age groups. Partially a consequence of better prevention of fatal events such as heart failure and stroke, more men seem to be surviving until oldest age in order to die from advanced-stage cancer. This is among the many factors, now partially understood, that account for the 33% increase in cancer mortality among men aged at least 85 between 1950 and 2016. More research is needed to determine much of this disparity is due to sex hormone differences or to gender differences in health behaviors such as preventative screening.

FIGURE 2-7. Mortality rate for malignant neoplasms by age, sex, and year: United States, 1950–2016. (Data from National Center for Health Statistics; 2017. https://www.cdc.gov/nchs/data/hus/2017/024.pdf .)

The most common chronic conditions among Medicare beneficiaries aged 65 and older are presented in Table 2-4. Hypertension is the most common chronic condition and a risk factor for cardiovascular disease, and is prevalent in over half of older adults. Hyperlipidemia, another risk factor for cardiovascular outcomes, is the second most chronic condition and impacts 41% of older men and women. Ischemic heart disease, arthritis, diabetes, and chronic kidney disease affect over one-fifth of older men and women.

There are important gender differences in the prevalence of many conditions. Arthritis, depression, and osteoporosis are more common among women, whereas ischemic heart disease is more common among men.

TABLE 2-4 ¦ MOST COMMON CHRONIC CONDITIONS PER 100 MEDICARE BENEFICIARIES 65 YEARS AND OLDER IN 2017

It is important to note that these prevalence estimates were based on Medicare claims, and thus would not capture undiagnosed conditions.

Discrepancies between claims-based estimates and true prevalence of conditions are highest for asymptomatic conditions, such as hypertension and hyperlipidemia, and in marginalized populations, such as individuals experiencing homelessness, those who are incarcerated, and those who reside in long-term care. Population-based surveys and epidemiologic cohort studies can provide more accurate estimates. These types of studies may use a combination of testing, examinations, and medical record review to more accurately diagnose chronic conditions. However, even these studies do not reach marginalized populations.

A core principle of geriatric medicine is that chronic conditions often occur in combination among older adults. Multiple chronic conditions are common among older adults. In 2018, 33% of adults 45 to 64 years had two or more chronic conditions, compared with 64% of adults 65 years and older. When one or more chronic conditions occur in relation to an index condition, this is often termed comorbidity; whereas when multiple chronic conditions occur together, this is termed multimorbidity. Multimorbidity accumulates with time, varies by ethnicity, and accelerates in later life. African-Americans have substantially higher levels of multimorbidity at every age, with similar age acceleration (Figure 2-8). Multimorbidity is a risk factor for multiple outcomes that include hospitalization, disability, and death, and comorbidity can increase the risk of outcomes associated with an index condition. For example, comorbidity can increase the risk of all-cause mortality among women with breast cancer, compared with women with breast cancer and no comorbid conditions. Moreover, comorbidity can complicate the treatment of a given condition, and certain therapies may be contraindicated, such as the use of diuretics to treat hypertension in the presence of comorbid gout.

FIGURE 2-8. Multimorbidity trajectories: non-Hispanic Black, non-Hispanic White, and Hispanic trajectories of chronic disease accumulation over time, HRS 1998–2014. (Reproduced with permission from Quiñones AR, Botoseneanu A, Markwardt, et al. Racial/ethnic differences in multimorbidity development and chronic disease accumulation for middle-aged adults. PLoS One. 2019;14[6]:e0218462.)

A common consequence is that people with multiple chronic conditions are often given multiple medications to treat those conditions. Most medications are evaluated one at a time in a single disease setting. While the benefit of treatment may be clear in this setting, the long-term benefits and harms associated with the combination of medications that are taking as a result of disease-specific treatment are less clear. Polypharmacy, or the use of multiple medications, is frequently associated with adverse outcomes including poor physical function, cognitive problems, and even death. Data on prescription drug use are shown in Figure 2-9. The number of prescription drugs used increases with age. Two-thirds of adults 65 years and older use three or more drugs, and 40% of this age group uses five or more. In response to concerns about medication overuse in older adults, many clinicians are considering deprescribing medications when the benefit

of a medication no longer outweighs the harms. Deprescribing is the planned and supervised process of dose reduction or stopping of medication.

FIGURE 2-9. Prescription medication use in the past 30 days by age, United States: 2013– 2016. (Data from National Center for Health Statistics; 2018. National Health and Nutrition Examination Survey. National Health and Nutrition Examination Survey (NHANES) https://www.cdc.gov/nchs/data/hus/2018/038.pdf .)

Another way to appreciate the burden of chronic conditions in older adults is to examine health care utilization. Table 2-5 illustrates that adults 75 years and older have the highest rate of ambulatory care visits of any age group based on data from the 2016 National Ambulatory Medical Care Survey.

Among every 100 adults 75 years and older, there is an average of 547 outpatient medical visits per year, or between five and six visits per person. This is about double what is observed in midlife, where the average rates are 205 per 100 persons per year for adults aged 25 to 44, and 302 per 100 persons per year for adults aged 45 to 64. Also notable is that over half of visits in adults 75 years and older are for a chronic condition, whereas this proportion is progressively smaller in younger age groups. The most common conditions reported at ambulatory care visits are hypertension, hyperlipidemia, arthritis, diabetes, and cancer.

TABLE 2-5 ¦ OUTPATIENT MEDICAL VISITS AND REASONS FOR THE VISITA ACCORDING TO AGE GROUP, UNITED

Based on data from the National Hospital Discharge Survey, heart disease is the top cause of hospitalization in persons aged 65 and older and accounts for nearly 600 hospitalizations per 10,000 people per year (Table 2-6). Among the different types of heart disease, heart failure results in the highest burden of hospitalizations, due to the recurrent nature of this

condition. After heart disease, the most common causes of hospitalization are cerebrovascular disease, pneumonia, cancer, fractures, osteoarthritis, septicemia, and urinary tract infections, which all have rates that exceed 100 hospitalizations per 10,000 people per year. These statistics not only represent a high burden of morbidity for patients, but a high cost to the health care system, which highlights the importance of prevention for these conditions.

TABLE 2-6 ¦ THE 10 LEADING CAUSES OF HOSPITALIZATION IN PERSONS AGED 65 AND OLDER, FIRST LISTED DIAGNOSIS IN UNITED STATES, 2010

The prevalence of cardiovascular disease, which includes heart failure, stroke, and coronary heart disease, rises sharply with age. Figure 2-10 illustrates the age-specific prevalence of these conditions among men and women. All increase with age, with coronary heart disease demonstrating the sharpest increase, reaching over 30% in men and 25% in women.

FIGURE 2-10. Prevalence of heart failure, stroke, and coronary heart disease (CHD) by sex and age in the United States. (Data from the National Health and Nutrition Examination Survey, 2013–2016. https://wwwn.cdc.gov/nchs/nhanes/Default.aspx.)

The incidence rate for most cancers rises with age, although some, such as prostate, breast, uterine, and lung cancer, decline in the oldest age groups as seen in Figure 2-11. Incidence data are available nationally from the Surveillance, Epidemiology, and End Results (SEER) survey of cancer registries. In both men and women, sex-specific cancers, prostate in men and

breast in women, have the highest incidence rates, peaking in adults in their early 70s.

FIGURE 2-11. Incidence rates of specific cancers in men (top panel) and women (bottom panel) by age. (Data from SEER Cancer Statistics Review 1975–2017. Surveillance, Epidemiology and End Results Program, National Cancer Institute. https://seer.cancer.gov/csr/1975_2017/.)

Sensory impairments are often overlooked when assessing the burden of chronic conditions but can contribute importantly to the quality of life and the ability to remain independent. Sensory impairments are often classified as a geriatric syndrome because their incidence increases with age and is often due to multiple different pathophysiologic causes. According to data from the National Health and Nutrition Examination Survey, one out of six Americans aged 70 and older has a visual impairment, one out of four has a hearing impairment, and three out of four have abnormal testing for postural balance. These numbers continue to increase with age and the prevalence of vision and hearing impairments in those aged 80 and older are over double that in adults in their 70s. Unfortunately, many older adults are undertreated for their impairments, and almost 60% of older persons with vision problems could

benefit from new or improved glasses, and 70% of older persons with hearing problems could benefit from a hearing aid. These statistics represent a missed opportunity for treatment to attenuate the detrimental effects of hearing and vision loss.

Older adults frequently report preservation of functional and cognitive health as their highest priorities for care. Maintenance of health in these domains allows older adults to engage in activities that enhance meaning in their lives. For some, this could mean being able to go for long walks or play with their grandchildren. For others, it could be the ability to continue working in their careers or engaging in volunteerism. Moreover, functional health is not only an important outcome on its own, but poor functional health is predictive of disability, loss of independence, institutionalization, and ultimately death. For these reasons, geriatric medicine has always prioritized preservation of functional health as a goal of care. In parallel, the epidemiology of aging has evolved as a discipline to study the distribution of functional health in older age, as well as risk and protective factors with the goal of informing interventions.

The terminology used to describe functional health is complex, so we begin with a brief overview. Functional health is a broad term that is often defined as an individual’s ability to perform activities in their daily lives, including both simple and complex activities. Disability is defined as difficulty completing usual activities, and is frequently assessed through difficulty or inability to complete one’s activities of daily living (ADLs): activities essential for self-care (eg, bathing, dressing oneself, using the toilet) (see Chapter 42). The distinction between difficulty and inability is meaningful and has led to variation in disability estimates across studies.

Instrumental activities of daily living (IADLs) refer to the activities that allow an individual to remain independent in the community (eg, driving, shopping, preparing food). Preceding the onset of a disability is often a

functional limitation, which refers to a restriction in basic physical action, such as difficulty crouching or kneeling. Mobility limitation refers to difficulty in walking or climbing stairs and is often measured by self-report. However, some experts have defined dismobility as a measured gait speed

less than 0.6 m/s or inability to walk 400 meters. Physical performance measures include objective measures of physical function such as walking, balance, and strength. One of the most common tools for evaluating physical performance is the Short Physical Performance Battery (SPPB), which includes a 4-meter gait speed test, chair stands as a measure of lower body strength, and balance.

Data from Medicare beneficiaries demonstrate the striking impact of age on the prevalence of disability and residence in a long-term care facility (Figure 2-12). With each decade of ascending age, the proportion of those with no disability drops from 66% in adults 65 to 74 years old to only 27% in adults 85 years and older. In this survey, disability was defined as serious difficulty hearing, seeing, concentrating, remembering, or making decisions, walking or climbing stairs, dressing or bathing, or with errands. Moreover, the prevalence of two or more disabilities increases from 15% to 38% in the same age groups, respectively. Notably, the prevalence of adults living in a long-term care facility reaches 13% among those aged 85 and older. These same data show modest sex differences, with women being more likely to have prevalent disability than men. Figure 2-12 also demonstrates disparities by race/ethnicity, with White non-Hispanic adults having the lowest prevalence of disability compared to Black non-Hispanic and Hispanic adults, yet the highest prevalence of long-term care. These inequities reflect the unequal conditions in which persons from different racial and ethnic backgrounds live in the United States.

FIGURE 2-12. Disability status among all Medicare beneficiaries by age, sex, and race/ethnicity. LTC, long-term care. (Data from Centers for Medicare and Medicaid Services. https://edit.cms.gov/Research-Statistics-Data-and-Systems/Downloadable-Public-Use- Files/MCBS-Public-Use-File/index.)

Figure 2-13A shows similar patterning for the prevalence of mobility disability, defined as self-reported inability to walk 1/2 mile or climb a flight of stairs without assistance. Women have a higher prevalence of mobility disability, and the prevalence increases with age for both women and men. The subsequent panels allow us to examine prevalence in the setting of the dynamics of disability and death. Prevalence is a function of incidence (Figure 2-13B), or new cases of mobility limitation, as well as death (Figure 2-13C) and recovery (Figure 2-13D). The incidence rate of new mobility limitation increases with age for both women and men (Figure 2-13B), but the differences are not as great as for prevalence. This is explained by evaluating the subsequent graphs; Figure 2-13C demonstrates that women living with a disability have lower mortality rates than men, thus contributing to greater prevalence at a given age. Men are slightly more likely to recover from mobility disability than women, although recovery declines in both groups by age (Figure 2-13D).

FIGURE 2-13. Women’s and men’s prevalence of mobility disability (A), 1-year incidence among nondisabled persons (B), and 1-year mortality (C) and recovery (D) among disabled persons, by age. Established populations for the epidemiologic study of older persons. (Reproduced with permission from Leveille SG, Penninx BW, et al. Sex differences in the prevalence of mobility disability in old age: the dynamics of incidence, recovery, and mortality. J Gerontol B Psychol Sci Soc Sci. 2000;55[1]:S41–S50.)

One of the foundational models of disability, known as the Disablement Process, was first published in 1994 by Lois Verbrugge and Alan Jette. In this model, pathology or disease can lead to impairments, described as dysfunctions or structural abnormalities in specific body systems. This, in turn, can lead to functional limitations, which is a restriction in a basic physical or mental action. Last in the sequence of events is disability, which is defined as difficulty doing activities of daily life. This Disablement Process model also acknowledges the role of the environment, risk factors, and person factors such as behavior and psychosocial attributes. An alternative model was presented in 2002 by the World Health Organization to describe the International Classification of Functioning, Disability, and Health (ICF). This model presents a biopsychosocial model of disability, which is viewed as an interaction between the features of a person and the context in which they live. Much like the Disablement Process, the ICF

model also posits levels of functioning that encompass health conditions, impairments, activity limitations, and participation restriction. However, there is increased focus on level of health, as well as a distinction between an individual’s capacity and performance, which is what a person does in their environment.

Regardless of the model used, it is important to understand that disability is not a fixed state, but a dynamic and bidirectional process. Many adults recover from disability and may report the onset and recovery of disability multiple times throughout their life course. One study in the United States found that impairment in ADLs developed in one-fifth of adults aged 50 to

64. Among this population with impairment, 2 years later, 4% had died, 9% had further declined, 50% had persistent impairment, and 37% had recovered. In another study of a population of African-American adults residing in Jackson, Mississippi, found that 32% had an incident mobility limitation, but nearly half had recovered within a year. The important takeaway for geriatric care is that, although avoiding an incident limitation is preferred, recovery after limitation or disability is likely. Interventions to facilitate recovery, prevent persistent disability, or further loss can help older adults to stay independent and actively engaged in their communities.

Finally, the dynamic process of disability can occur over different timescales. Often there is a distinction made between catastrophic disability, with the sudden onset of disability, such as after an acute event such as a stroke, and progressive disability, which can develop slowly over time. The Precipitating Events Project is one study that has illuminated the time scale of disability onset by contacting participants aged 70 and older monthly. By assessing individuals frequently, study investigators were able to describe disability onset using a more granular timescale than is usually evaluated in large-scale epidemiologic investigations. The investigators reported five different trajectories of disability in the last year of life, illustrated in Figure 2-14, highlighting the heterogeneity of this process: persistent severe disability, progressive disability, accelerated disability, catastrophic disability, and no disability.

FIGURE 2-14. Trajectories of disability in the last year of life among 383 decedents. The severity of disability is indicated by the mean number of activities of daily living in which the subjects had disability. (Reproduced with permission from Kurrle S, Cameron ID, Maier AB. Trajectories of disability in the last year of life. N Engl J Med. 2010;363[3]:294.)

Data from earlier discussion illustrate differences in disability by age, sex, and race/ethnicity. We next turn to risk factors for disability and poor functional health. Many chronic conditions are risk factors for disability, including cardiovascular disease, heart failure, osteoarthritis, chronic obstructive pulmonary disease, diabetes, cancer, depression, dementia, and sensory impairments. Moreover, the presence and burden of disability and functional limitations increases notably with the number of chronic conditions (Figure 2-15). This figure demonstrates the prevalence of up to 19 functional limitations (Figure 2-15A) and 7 ADL/IADL (Figure 2-15B) rises sharply with the number of chronic conditions. This graph also illustrates the higher burden of functional limitation and disability among women and those aged 75 and older.

FIGURE 2-15. Predicted mean number of limitations by the number of chronic conditions, stratified by sex and age group. Abbreviations: ADL, activities of daily living; IADL,

instrumental activities of daily living. (Reproduced with permission from Jindai K, Nielson CM, Vorderstrasse BA, et al. Multimorbidity and Functional Limitations Among Adults 65 or Older, NHANES 2005–2012, Prev Chronic Dis. 2016;13:E151.)

A healthy lifestyle can not only prevent disease but disability as well. There is a substantial body of work that has demonstrated that no smoking, healthy diet, and physical activity can all reduce the risk of disability. In 2014, investigators in the Lifestyle Interventions and Independence for Elders (LIFE) study found that a structured, moderate-intensity physical activity program reduced the risk for major mobility disability by about 20% over 2.6 years. The intervention included aerobic, resistance, and flexibility training activities in a center and at home. The study targeted adults at risk for disability, demonstrating that disability is to some extent preventable.

Cognitive impairment and poor functional health are interrelated and often follow similar epidemiologic patterns. Figure 2-16 illustrates the number of men and women with disability with and without dementia in three population-based studies in the Tuscany region of Italy in 1999. One can see that these conditions are similarly distributed across the age spectrum in men and women. The dip in the number of people living with a disability in these studies with and without dementia among persons around 80 years of age is due to the low birthrate during and shortly after World War I. Dementia is a determinant of limitations in IADLs, such as paying bills or shopping, where problems in memory can limit an individual’s ability to complete these tasks. Dementia is also a risk factor for other types of functional limitations and disability, and conversely, functional limitation is also a risk factor for dementia. The bidirectional relationship between cognitive and physical function is an important active area of research. The potential clinical implication is that patients with limitations in one domain may be more likely to develop limitations in another.

Disability is commonly considered a key indicator of older adult health; it is patient-centered outcome, and also tightly connected to an individual’s ability to remain independent and age in place. The prevalence of disability is also a measure of caregiving required by a population, either in the form of at-home or institutionalized care. For these reasons, researchers have monitored trends in disability, through large-scale nationally representative surveys. Monitoring temporal trends is challenging due to confounding by age and birth cohort effects, as well as trends that vary by characteristics of the population (ie, age, sex, geography) and the measurement tools used.

In general, there have been declines in disability prevalence over the past several decades, although this decline appears to have slowed or stopped around the turn of the millennium. Freedman et al. pooled results from five large surveys from 2000 to 2008: the Health and Retirement Study, the Medicare Current Beneficiary Survey, the National Health Interview Survey, the National Health and Nutrition Examination Survey, and the National Long Term Care Survey. The researchers found that disability prevalence was relatively stable for those aged 65 to 84, and appeared to be increasing among 55 to 64 years and decreasing among 85 years and older. These

findings likely reflect the converging influences of advances in the care of older adults, especially the oldest old, as well as temporal increases in disability risk factors such as obesity and inactivity. Research has demonstrated physical activity, a cornerstone of disability prevention and requires environmental and societal resources, such as sidewalks and safety, in addition to individual decision-making.

Along with physical function, preservation of cognitive function remains a top goal of care for older adults. Cognitive impairment and dementia are associated with worse quality of life, disability, loss of independence, and death. Moreover, cognitive function and physical function are intertwined, with decrements in one contributing to another.

Various instruments have been used to assess cognitive function in epidemiologic studies (see also Chapter 9). Commonly used tests include the Mini-Mental State Exam, Modified Mini-Mental State Exam, and the Montreal Cognitive Assessment, which are measures of global cognitive function, and the Digit Symbol Substitution Test, a measure of processing speed, and others. Some tests are better at detecting low function than high function such that highly educated older adults may perform at the test ceiling in spite of early cognitive decline. Moreover, tests may be insensitive for small declines in cognitive function.

The gold standard for clinical Alzheimer disease and dementia diagnosis is through a neuropsychological evaluation with a full battery of cognitive tests, a neurologic examination, and brain imaging. However, many epidemiologic studies use other data sources such as medical record review including ICD codes, medication use, death certificates, and brief cognitive tests to define dementia. Each of these sources is subject to misclassification and thus the incidence and prevalence of dementia may be biased, as well as any associations with risk factors. For example, one systematic review found that the positive predictive values of codes for dementia diagnosis ranged from 33% to 100% and sensitivities ranged from 21% to 86%. Nonetheless, the widespread availability of electronic health records and claims data has increased the use of these alternative data sources to ascertain dementia.

include sensitivity analyses such as quantitative bias analysis to evaluate the potential impact of the misclassification on study findings.

The prevalence of mild cognitive impairment increases with age; a recent systematic review found that the prevalence of mild cognitive impairment was 6.7% for ages 60 to 64, 8.4% for 65 to 69 years, 10% for 70 to 74

years, 15% for 75 to 79 years, and 25% for 80 to 84 years. The epidemiology of dementia follows a similar pattern with age. Figure 2-17 illustrates the increase in dementia cases with age. Notably, women have more dementia than men after the mid-70s. These data were obtained from a pooled study of 11 European population-based studies. Incidence rates of dementia were 2.4 per 1000 person-years in adults aged 65 to 69, 5.5 in 70

to 74 years, 16 in 75 to 79 years, 31 in 80 to 84 years, 49 in 85 to 89 years, and 70 per 1000 person years in those aged 90+. Risk factors for cognitive impairment and dementia include lower educational attainment, cardiovascular disease, hypertension, diabetes, obesity, and apolipoprotein e-4 genotype.

FIGURE 2-17. Pooled prevalence of dementia by sex and age in 11 pooled cohort studies in eight European countries. (Reproduced with permission from Lobo A, Launer LJ, Fratiglioni L, et al. Prevalence of dementia and major subtypes in Europe: a collaborative study of population- based cohorts. Neurologic Diseases in the Elderly Research Group. Neurology. 2000;54[11 Suppl 5]:S4–S9.)

Biomarkers measure aspects of biologic processes in blood or urine or with physiologic monitoring or imaging. Associations of biomarkers with outcomes can indicate the level of risk or inform on biologic underpinnings. While many biomarkers have been studied for specific diseases, interest is turning to biomarkers of the aging process itself. A biomarker of aging is conceptualized along two main dimensions: first as a marker or set of markers that captures the state of one or more fundamental aging hallmarks and second, markers that can predict outcomes at least as well, if not better than, chronological age. Hallmarks of aging include inflammation, mitochondrial dysfunction, protein misfolding, impaired autophagy, and telomere shortening, among others. These have proven to be challenging to measure in epidemiologic studies, as they often require fresh blood or tissue. However, there is hope that new markers that more closely reflect aging biology could be useful to track aging over time and ultimately to assess responses to preventive measures that promote healthy aging.

Interleukin-6 (IL-6), a marker of inflammation, is one of the most robust biomarkers of aging, predicting many adverse aging outcomes. Interleukin-6 is a cytokine produced by activated immune cells, muscle, and fat, signaling the liver to induce C-reactive protein. An IL-6 level of 2.5 pg/dL may appear to fall in the upper normal range for community-dwelling older adults, but levels in this range robustly predict decline in strength, walking speed, and mortality in observational studies of older adults. Along with experimental studies in animal models, these studies support the hypothesis that directly lowering IL-6 could prevent age-related disability. Based on this hypothesis, a clinical trial, ENRGISE tested whether IL-6 could be reduced with either fish oil or losartan. While there was no change in either IL-6 levels or walking speed with either intervention, the study provided a roadmap for translating biomarker associations in epidemiologic studies to targeted intervention clinical trials in aging. Another biomarker is telomere length, which is thought to mark biologic age as the length of the telomeres shortens with each cell division. When critical shortening is reached, cell senescence ensues. Epidemiologic studies of telomere length have been inconsistent, perhaps because most studies use mixed populations of white cells from peripheral blood. Telomere length is also quite variable and difficult to track over time. Nevertheless, telomere biology is clearly important in cell

senescence and cancer biology, warranting continued interest in the biology of telomere loss and maintenance.

Increasingly, panels of biomarkers are being used to detect hundreds or thousands of unique molecules circulating in the blood, ranging from single nucleotide polymorphisms in the DNA (genomics), metabolites (metabolomics), proteins (proteomics), or the composition of microbes in body fluids (microbiome). By harnessing these “-omics” technologies to study population aging, new pathways or targets for healthy aging might be identified.

Genomics and epigenetics are well-established among the “-omics” methods. Genome-wide association studies (GWAS) have linked specific risk alleles to a broad array of aging outcomes such as walking speed and muscle strength or longevity. Prior to the GWAS era, the APOE4 genotype had already been established as a risk factor for cardiovascular disease and dementia. More recently, polymorphisms in this region of the genome have been found to predict longevity. The methylation of DNA, which controls transcription, clearly changes across the lifespan. By correlating methylation patterns with chronologic age, “methylation clocks” have been developed.

The mechanisms of these associations are not well understood, yet changes in methylation age have been proposed as a potential agnostic marker of interventions purported to impact biologic aging.

Proteomic studies evaluate proteins that serve as enzymes or transcription factors in cellular processes. Growth differentiation factor 15 (GDF-15) has been identified in proteomic analysis as strongly related to mobility disability disease and frailty. Groups of proteins can be evaluated for the degree to which they fall into a pattern for a particular biologic pathway. For example, pathway analysis has revealed that signaling pathways of inflammation and phagocytosis are related to mobility disability.

Metabolomics include the circulating products of metabolism, such as lipids, alcohols, and amino acids. Several different platforms are needed to assess lipophilic and hydrophilic molecules. Many of the molecules that can be measured are as yet unknown or are adducts or other byproducts that are artifacts. Early studies have examined obesity and frailty, which are thought to have distinct metabolic fingerprints that may better define the underlying biology. More studies are needed that assess metabolic changes with specific interventions and diets.

Summary measures of health have been used to approximate biologic age by validating scores of deviation of multiple laboratory tests and physiologic measures against mortality risk. Many of these measures do not seem to have substantial correlation with telomere length or methylation age, although neither of these would be considered as gold standards. Currently, composite measures of biologic age are more accessible than blood measures as most rely on clinically available information. In a study of caloric restriction (CALERIE), a composite measure of biologic age increased less in calorically restricted adults. Such studies illustrate the potential utility of understanding the global impact of interventions on health and aging.

Whole person physiologic measures can also be biomarkers. One of the most well-validated is gait speed, which can be viewed as summarizing aging in multiple systems. Longer endurance walks and treadmill stress tests can also be considered as biomarkers as loss of exercise capacity is clearly age- related, even among the most fit master’s athletes. Blood pressure and pulse wave velocity can detect vascular stiffening, a strongly age-related physiologic process. Some of the composite measures of biologic age use such measures in combination with or without blood laboratory tests.

Imaging has been used to assess many systems. Brain aging can be defined by the degree of overall brain atrophy and increases in white matter hyperintensities on brain MRI. Such measures have been validated as biomarkers in that they are strongly age-associated and predict future morbidity and mortality in epidemiologic studies. Imaging has also been used to describe the age-related loss of muscle mass and the central infiltration of body fat. Fat infiltration of muscles and organs is clearly related to worse metabolic health and appears to progress with aging, even without overall obesity or disease. Whether body composition can serve as a biomarker of aging per se is still controversial as muscle mass has been more difficult to measure precisely. New imaging or isotope tracer methods may better define the role of these measures as biomarkers.

Epidemiology can support the study of aging by identifying modifiable risk factors for accelerated aging and/or longevity and their biologic pathways.

Beyond individual biomarkers, multi-omics studies can link genes to proteins to metabolites and these factors to biomarkers of intermediate-aging phenotypes. Physiologic measures and imaging can summarize the state of aging at the level of individual organs. Together these can create a deeper understanding of the aging process in population studies and identify new opportunities for prevention and treatment of the adverse effects of aging.

Health behavior can precipitate or slow functional decline among older adults. Studies conducted among twins and family members indicate that, for the first eight decades of life, environmental factors are stronger predictors than genetics of health and survival. Surveillance from the Centers for Disease Control and Prevention (Table 2-7) indicates that adults aged at least 65 have a lower likelihood of reported binge drinking and smoking compared with middle-aged adults. Potentially due to increased need of medical care, older adults are the age group that reports regular routine checkups and immunization. Over the life course, the effect of behavior on disability and lifespan appears to attenuate. The updated framework for biomedical research involves contextualizing patterns of health behavior with social circumstances. Further research needs to identify the ideal interplay of modifiable lifestyle and environmental factors that grant older adults more disability-free life-years.

TABLE 2-7 ¦ BEHAVIORAL RISK FACTORS IN MIDDLE-AGED AND OLDER PERSONS, UNITED STATES, 2018

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A plurality of randomized controlled trials among older adult populations target specific health behaviors to slow disease progression or reduce the incidence of functional decline. Smoking abstention or cessation, regular physical activity, and healthy diet are certainly recommended for the preservation of older adult health and independence. However, the associations between individual behaviors and health outcomes appear to weaken among older adult populations in observational data as well as in randomized trials. Compared to those assigned to health education control groups, older adult participants engaging in behavioral intervention arms commonly experience modest reduction in the incidence of transient or permanent impairment over follow-up. The smaller than expected differences in incident mobility limitation between trial groups may be attributable to the community benefit that the control participants receive. Additionally, the

long-term effect of such interventions remains understudied among older adults, whose average risk of functional decline increases due to the concurrent accumulation of chronic conditions and loss of social resources. The research into the determinants of healthy aging accordingly incorporates factors that influence and eventually supersede the effects of individual behavior.

Low socioeconomic status (SES) has been associated with higher rates of disability and mortality. Whether operationalized as educational attainment, income, or main occupation, higher SES can provide the resources (eg, time, information, money) necessary to engage in positive health behaviors over the lifespan. Higher parental SES both determines adult SES and is associated with better cognitive reserve (good cognition in the face of brain pathology) in observational studies of dementia. In a nationally representative sample of US older adults, attainment of a high school degree or equivalent was associated with greater cognitive function, while late-life income was a more deterministic of cognitive decline. Compared to current individual income, household wealth may better characterize the finances available to adults at retirement age. Wealth is the net value of assets, investments, businesses, and property value minus debts. Older adults lacking wealth may be reliant on state-funded pensions far below their earnings during working years. Belonging to the lowest versus highest quartile of wealth was associated with greater 8-year declines in grip

strength and gait speed among English older adults. Furthermore, the socioeconomic differentials in healthy aging appear to be widening over time. Wealthy adults born in 1960 have fewer reported functional impairments and better cognitive performance than their same-age counterparts born in 1915. The influence of SES on older adult health is cumulative, complex, and may be subject to cohort effects.

Access to more economic and political resources facilitates successful avoidance of premature morbidity and mortality. The unequal distribution of resources has historically been drawn along racial and ethnic lines.

Biomedical research is shifting from treating racial or ethnic identity as a homogenous and innate, instead understanding self-assigned background as a proxy for aggregated elements including cultural norms and discriminatory treatment. Discrimination includes both interpersonal experiences including harassment and police brutality, as well as structural inequality including redlining and biased bank loan practices. Forms of discrimination, such as racism, can also be internalized, that is, members of marginalized groups accepting as fact the stereotypes propagated by the majority. Beyond inducing psychological stress and physiologic dysregulation, discrimination motivates adverse coping mechanisms, reduces the likelihood of engaging in health- promoting behaviors, and restricts socioeconomic mobility. David Williams has developed one of the earliest psychometric scales to assess discrimination. Initially used to characterize racism experienced by Black Americans, these measures have been implemented and validated among diverse groups to assess discrimination attributable to gender, class, sexual orientation, and age. Analogous to discrimination based on race or ethnicity, cultural prioritization of younger people devalues older adults in the health care and employment spheres. Ageism manifests as detrimental treatment of older adults along with the negative aging stereotypes held by the society, health care providers, and older adults themselves. Compared to older adults reporting no discrimination due to age and after controlling for baseline health status, more experiences of ageism are associated with lower preventative health care use, greater stress, poor balance, and impaired cognitive performance. Conversely, even older adult carriers of e4 variant of the APOE gene who expressed positive aging beliefs scored better on the telephone interview for cognitive status than carriers who expressed negative

aging beliefs. Understanding the impact that various forms of discrimination have on older adult health improves the equity of medical care.

Acculturation involves both maintaining attitudes and beliefs from the culture from which a person originates and developing new ties with a dissimilar and usually dominant culture. Strategies for acculturation include integrating these new cultural beliefs with original ideas, entirely assimilating the attitudes of the new culture to replace original ones, separating from the attitude of the new culture by remaining in original cultural enclaves, and being marginalized by not identifying with either their original or new culture. Though acculturation can be crudely approximated by immigration status, language use, and duration of residence in new country, culturally specific tools such as the Acculturation Rating Scale for Mexican Americans–Version II have been developed to better assess how individuals perceive identity, utilize language, and engage in interpersonal interactions. Context as individualized as immigration experience or as system-level as discriminatory legislation can influence both acculturation patterns as well as health outcomes. Highly acculturated people tend to smoke, consume more alcohol, and have unhealthier diets; they are also more likely to exercise, have higher SES, and have greater health care access as well as utilization.

The built environment is comprised of the buildings, public spaces, roads, and infrastructure where communities live, work, and socialize. After retirement, people spend more time near their area of residence, making the built environment increasingly deterministic of older adult health outcomes. Features of the built environment that facilitate independence among community-dwelling older adults include proximity to health-promoting resources, including medical providers as well as healthy food options.

Meanwhile, extreme weather conditions, high ambient noise, poor street conditions, and heavy traffic can prevent independent mobility. A strengthening evidence base continues to reframe health policy around positive neighborhood features: for example, low crime, cleanliness, adequate street lighting, and land use consisting of a diverse mix of residential, commercial, and natural locations.

A positive-built environment can promote community engagement among older adults; this can counteract the tendency of social networks to shrink with age due to personal functional decline as well as life stage changes including retirement, widowhood, and the death of peers. Older adults increasingly rely on interpersonal resources and networks called social capital to maintain their mental and physical health. Researchers use psychometric scales such as those developed by the Chicago Neighborhood and Disability Study and the Chicago Health and Aging Project to survey about neighborhood disorder, such as vacancies and low safety, along with social cohesion, which involves a perception of a neighborhood that promotes a sense of belonging.

The Administration for Community Living estimates that a quarter of people aged at least 65 live alone. Scales such as the UCLA Loneliness Scale assess subjective isolation with items such as “I feel isolated from others” and “I am unhappy doing so many things alone.” The Berkman-Syme Social Network Index assesses the type of support received from partners, friends, family members, religious as well as community groups. Expressions of empathy, tangible aid, and advice all comprise distinct forms of interpersonal contact whose absence indicates social isolation. Among Framingham Heart Study participants, perceived social isolation was cross- sectionally associated with lower levels of serum brain-derived neurotrophic factor (BDNF), while higher levels of emotional support corresponded with lower rates of stroke and dementia over the subsequent 11 years. The health benefits vary by intensity and frequency of support, independent of network size; not all social contacts are beneficial. Older adults can experience loneliness, irrespective of the objective size of their social network, making the subjective indicators of isolation interrelated but not mutually exclusive.

Older adult health outcomes are nested within multilevel determinants at the individual and societal level. Features of the built and social environment can increase the likelihood of engaging in health-promoting behaviors.

Neighborhoods rich in resources are associated with better subjective and objective measures of health. Beyond promoting positive health behaviors, intrapersonal and interpersonal resources appear to influence each other as well as promote meaningful participation in society. Insufficiently supportive social networks, resource-poor environments, and social stratification render older adults vulnerable to excess morbidity and disability.

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Immunosenescence refers to the changes in the immune system that occur with aging. These changes affect virtually all cell lineages of the immune system, and result in alterations in diverse innate immune responses mediating the earliest interactions of the immune system with pathogens or vaccines, as well as slower onset, highly specific adaptive immune responses in B cells and T cells. Indeed, these changes extend to hematopoietic stem cells (HSC) in the bone marrow that give rise to all cell lineages of the immune system.

These immunological alterations are manifested in changes in cellular signal transduction or function that may arise from intrinsic mechanisms with a genetic component, but also reflect the complex interactions of the aged immune system with factors such as chronic or repetitive infection (such as with herpesvirus family reactivation or HIV), hormonal changes, and endogenous cellular damage as a potential result of chronic medical conditions. Immunosenescence has profound clinical consequences in older adults, who are at increased risk for morbidity and mortality from infectious diseases. For example, older adults are at increased risk for the development of reactivation tuberculosis and varicella zoster virus (VZV) infection; age is also an independent risk factor for mortality and impaired functional outcome from sepsis and infection with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the cause of COVID-19. Immune system aging also contributes to impaired responses to vaccines against influenza and other pathogens. The protean manifestations of immunosenescence provide insights into clinically important problems that disproportionately affect

older adults and potential interventions to improve immunologic responses. Here, we provide an overview of aging of the human immune system.

HSCs in the bone marrow give rise to all blood cell lineages (Figure 3-1) and as a result must maintain their ability to both differentiate and self-renew so that hematopoiesis can continue throughout life. The effects of aging on HSCs are complex; for example, HSC numbers appear to increase with age, rather than the decrease that might be expected. Aging is associated with impaired differentiation and repopulation of blood cell lineages upon transplantation; this has been most clearly demonstrated in model mouse systems, although the substantial effect of donor age on outcomes from HSC transplantation suggests a similar effect in humans. Notably, there appears to be a significant bias favoring development of progenitor stem cells for the myeloid lineage (which give rise to granulocytes, monocytes, macrophages, erythrocytes, and platelets) and diminished numbers of lymphoid progenitors responsible for B and T lymphocyte development. This likely contributes to the impairment in B and T cell development found in older adults, and it is attractive to speculate that increases in myeloid progenitors could contribute to age-associated myeloproliferative disorders. The mechanisms underlying these alterations in hematopoiesis remain incompletely understood, but likely involve stem cell-intrinsic changes such as the accumulation of cellular and DNA damage (with age-related chronic inflammation likely playing a contributing role) and telomere shortening in HSCs with age, as well as inefficient DNA replication and alterations in signaling pathways mediating the response to DNA damage. In addition, changes in the bone marrow microenvironment that interacts with HSCs to facilitate their maintenance, renewal, and differentiation are also likely to contribute; one example of this is the increased fat cell content of bone marrow with age, which may alter the production of cytokines, chemokines, and other factors influencing HSC function.

FIGURE 3-1. Schematic representation of hematopoiesis. Hematopoietic stem cells (HSCs) differentiate into lymphoid progenitors in the bone marrow that give rise to T cells (which develop in the thymus) and B cells, and myeloid progenitors that differentiate to monocytes, dendritic cells, neutrophils, basophils, eosinophils, as well as erythroid and megakaryocytic lineages. Aging is associated with impaired HSC differentiation and repopulation function and with a bias toward myeloid at the expense of lymphoid progenitors.

The earliest onset responses to pathogens or vaccines are mediated by the innate immune system. Innate immune responses are mediated by a network of cells including epithelial cells, neutrophils, monocytes, dendritic cells (DCs), natural killer (NK) cells, basophils and eosinophils, and by biochemical factors including complement, antimicrobial peptides (defensins), proinflammatory cytokines, and antiviral interferon responses (Table 3-1). Such responses include pathogen clearance via intracellular killing (in neutrophils and macrophages/monocytes), killing of virus-infected or malignant cells (by NK cells), and complement fixation and lysis of extracellular organisms.

TABLE 3-1 ¦ COMPONENTS AND FUNCTIONS OF THE INNATE IMMUNE SYSTEM

Pattern Recognition Receptors of the Innate Immune System Another crucial function of the innate immune system is to activate

proinflammatory cytokine and chemokine production, particularly in cells such as DCs or monocytes, which present peptides derived from pathogens in conjunction with a host major histocompatibility antigen for recognition by T cell antigen receptors. Activation of such antigen-presenting cells (APCs) results in the expression of so-called costimulatory molecules such as CD80 and CD86—proteins that interact with a ligand on the surface of T cells to provide a critical additional signal (in conjunction with that provided by engagement of the T cell receptor [TCR]) for T cell activation. This innate proinflammatory response and upregulation of costimulatory protein

expression are mediated by a series of invariant innate immune pattern recognition receptors (PRRs). Toll-like receptors (TLRs) are one family of PRRs that are associated with either extracellular or intracellular membranes and recognize highly conserved, so-called pathogen-associated molecular patterns (PAMPs) found in bacteria, mycobacteria, fungi, and viruses.

Examples of PAMPs recognized by TLRs include lipopolysaccharide (LPS) and flagellin on gram-negative bacteria (TLR4 and TLR5, respectively), lipopeptides found in bacteria, mycobacteria, and yeasts (recognized by the TLR1/2 and TLR2/6 heterodimers, respectively). While these TLRs are expressed as membrane-associated receptors on the cell surface, other TLRs recognizing nucleic acids are localized to intracellular endosomal plasma membranes; such TLRs are activated by single-stranded RNA (TLR7 and TLR8) and double-stranded RNA (TLR3) produced during viral infections, as well as unmethylated CG-rich DNA (TLR9). Activation of TLRs on APCs engages signal transduction pathways employing myeloid differentiation primary response gene 88 (MyD88) or a pathway including the toll- interleukin-1 receptor (TIR)-domain-containing adapter-inducing interferon- ß (TRIF) protein and TRIF-related adaptor molecule (TRAM), resulting in not only upregulation of costimulatory proteins but also production of proinflammatory cytokines such as IL-6 and TNF-a via activation of the NF- ?B transcription factor, or production of type I interferons via interferon regulatory factor (IRF) engagement (eg, IRF3 and IRF7). By activating APCs presenting antigen to T cells, such TLR signaling links the innate immune response to adaptive immunity.

Recent studies have also identified families of PRRs localized to the cytoplasm (in contrast to the membrane localization of TLRs) that also include receptors recognizing viral RNAs (retinoic acid-inducible gene-I [RIG-I] and melanoma differentiation antigen-5 [MDA-5]) that interact with a mitochondria-localized signaling intermediate (mitochondrial antiviral signaling protein [MAVS]) are particularly important for antiviral interferon responses. Cytosolic DNA (that can arise in the context of infections—such as with DNA viruses—or DNA damage, such as in cancer) is recognized by numerous innate immune sensors including cyclic GMP-AMP synthase, gamma interferon inducing protein (IFI)-16, and others; the stimulator of interferon genes (STING) protein plays a central role in inducing type I interferon production following activation by such a DNA sensor. A member of the nucleotide-binding oligomerization domain (NOD)-like receptor

family, NLRP3, has emerged as an example of an innate immune PRR that responds to not only bacterial and viral motifs but also so-called damage- associated molecular patterns (DAMPs). NLRP3 activation results in assembly of a multiprotein complex termed the inflammasome, a multiprotein complex containing the adaptor protein ASC (apoptosis-associated speck- like protein containing a CARD [caspase activation and recruitment domain]) polymerized into helical filaments that can be visualized using immunofluorescence as a protein “speck” within cells. The CARD domains of these multimerized ASC proteins then mediate the activation of caspase-1 and the consequent proteolytic processing of immature forms of proinflammatory cytokines such as IL-1ß and IL-18 to their mature, active forms. DAMPs activating NLRP3 include exogenous factors such as silica and asbestos, and endogenous factors such as uric acid, extracellular ATP, and necrotic cells. The activation of innate immune inflammatory responses by such endogenous DAMPs is hypothesized to be a contributing factor to the increased levels of inflammation found in older adults, as discussed below.

The effects of age on innate immunity are complex, and reflect the diversity of innate immune responses. Increased levels of proinflammatory cytokines such as IL-6 and TNF-a, acute phase reactants such as C-reactive protein (CRP), and clotting factors are found in the plasma of older, compared to young adults; this age-associated chronic inflammatory state was first referred to by Franceschi as “inflammaging.” Inflammaging, as manifested by such elevated cytokine levels, is associated with mortality risk in cohorts of older adults, and is also correlated with decreased muscle mass and strength. In this regard, it is also notable that several diseases of aging, such as cardiovascular disease, diabetes, Alzheimer disease, and osteoporosis, are reported to have an inflammatory component that contributes to pathogenesis. The mechanisms underlying inflammaging remain incompletely understood, but are hypothesized to include activation of innate immune PRRs by PAMPs arising from chronic infections (such as viral infections with herpesvirus family members, or HIV infection, which is associated with increased inflammatory parameters even in individuals with nondetectable viral loads); in addition, age-associated accumulation of DAMPs such as noncell- associated nucleic acids, mitochondria, ATP, urate crystals, heat shock proteins, ceramide, hyaluronan, amyloid, and others resulting from cellular

or tissue damage leads to activation of innate immune PRRs such as TLRs and the NLRP3 inflammasome. Defects in autophagy with aging may result in reduced ability to dispose of damaged cellular elements, exacerbating the chronic inflammatory state. In this regard, Campisi and colleagues have described the senescence-associated secretory phenotype (SASP), a secretome of proteins released by damaged cells that includes chemokines and proinflammatory cytokines such as IL-6 and IL-8—another link between cell damage and inflammation (Figure 3-2). The inflammatory environment in older adults can also be influenced by additional factors; for example, both testosterone and estrogen suppress IL-6 production, with reduced sex hormone levels of menopause and andropause associated with increased cytokine levels. Finally, increased mitochondrial function with aging and associated uncoupling of oxidative phosphorylation could result in increased levels of reactive oxygen species that may also increase proinflammatory cytokine production.

FIGURE 3-2. Depiction of potential factors that contribute to age associated chronic inflammation. SASP, senescence-associated secretory phenotype.

TABLE 3-2 ¦ AGE-RELATED CHANGES IN INNATE IMMUNE CELLS

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Neutrophil function in older adults In cells of the innate immune system, age- associated changes include both impaired responses and inappropriate persistence of inflammation that may result from alterations in signal transduction. For example, neutrophils from older adults show diminished signaling via the granulocyte-macrophage colony-stimulating factor (GM- CSF) receptor that usually mediates antiapoptotic cell survival. Impaired age-associated signaling via the triggering receptor expressed on myeloid cells-1 (TREM-1) may also contribute to functional alterations in cytokine or reactive oxygen species (ROS) production. Human neutrophils also show an age-associated decline in migration toward a chemical stimulus (chemotaxis) and in phagocytosis and intracellular killing of engulfed pathogens. In addition, the release of neutrophil extracellular traps (NETs), complexes of DNA, histones, and antimicrobial proteins released from the neutrophil that facilitate pathogen capture and killing, is also decreased in neutrophils from older compared to young adults. While alterations in specific signaling pathways as discussed above have been linked to some of these findings, how age influences these functions remains unclear, particularly in view of the short lifespan of human neutrophils in vivo (approximately 5 days). It should be noted that alterations in function such as chemotaxis that may influence migration to sites of infection or injury could result in not only impaired migration to sites of infection or wound healing, but also impaired egress of neutrophils from these sites—potentially resulting in an inappropriate prolongation of the inflammatory response. In this regard, the clearance of apoptotic neutrophils by macrophages (a process termed efferocytosis) in a skin blister model of sterile inflammation was diminished in older, versus young adults, and was associated with elevated activation of macrophage p38 mitogen-activated protein (MAP) kinase; in vivo administration of an orally administered p38 inhibitor restored efferocytosis

and inflammatory resolution, suggesting an additional approach to modulating age-related inflammatory dysregulation.

NK cell function in aging Age-associated decline in function has also been reported for NK cells, a class of innate immune lymphocyte sensitive to cytokine activation, which plays an important role in killing virus-infected cells and in immunosurveillance against malignant cells. Critical proteins for the killing function of NK cells include proteases known as granzymes (for their storage in cytoplasmic granules), and perforin, a protein that forms a pore or channel in the target cell through which granzymes may be introduced. Inhibitory NK cell surface receptors recognize host class I major histocompatibility complex (MHC) protein expression and prevent apoptosis, but with loss of MHC class I expression—as frequently occurs on tumor cells to facilitate evasion of antitumor T cell responses—NK- dependent killing via apoptosis of target cells ensues. NK cells also express surface receptors recognizing the so-called Fc constant region of antibodies, and may thereby also mediate killing of targets bound to immunoglobulin—a process termed antibody-dependent cytotoxicity. With age, the proportion of NK cells specialized for cytotoxicity (as assessed by low expression of the surface CD56 adhesion protein) increases at the expense of NK cells specialized for cytokine production (which express high levels of CD56).

However, the cytotoxic function of aged NK cells is decreased on a per cell basis, likely in part resulting from diminished recruiting of perforin to the target cell. Studies of NK cell function in the context of aging are likely to have future clinical impact; notably, NK cell counts and measures of NK function have been associated with mortality from sepsis and other critical illness, and with increased infection and mortality rates in older nursing home residents.

Age-associated alterations in PRR function The effects of aging on human innate immune PRR function such as TLRs show evidence for an age-associated impairment in TLR-dependent expression of costimulatory proteins on monocytes, likely influencing the ability of these cells to serve as APCs that can maximally engage T cells. In addition, TLR-induced production of proinflammatory cytokines such as IL-6 and TNF-a in APCs such as monocytes and DCs is also diminished in cells from older adults. In particular, TLR1/2-induced cytokine production (in response to triacylated lipopeptides such as those found in many gram-positive organisms) appears diminished in monocytes from older compared to young adults. TLR function has also been evaluated in human DC populations, which may be predominantly divided into myeloid DCs, which express a wide range of

TLRs and mediate production of IL-12 for activation of T cell immunity, and plasmacytoid DCs, which express a narrower range of TLRs but are particularly adept at type I interferon production in response to viral infection. For both of these DC subtypes, a generalized age-associated decrease in TLR-induced cytokine production has been observed. At the same time, it is important to recognize that these studies largely represent in vitro assessments of TLR function. In vivo tissue context is likely to be an important factor; for example, evaluation of TLR function in monocyte- derived DCs showed an age-associated increase in cytokine production; such DCs are derived from monocytes using growth factors and cytokines (GM- CSF and IL-4), and could model DCs generated in the context of inflammation. LPS (recognized by TLR4)-induced cytokine production also appears increased in so-called CD14+CD16+ monocytes (as opposed to CD14+CD16- conventional monocytes) that arise in the setting of inflammation-associated conditions such as sepsis, HIV infection, and myocardial infarction. As a final example, TNF-a production by macrophages in human skin was diminished in the setting of a delayed-type hypersensitivity response to purified protein derivative (PPD)—yet TNF-a production in vitro by such macrophages was preserved, arguing for the importance of local factors (such as the potential influence of regulatory T cells in the skin of older adults, in this case) in assessing innate immune function.

The mechanisms underlying these age-related changes remain incompletely understood; some changes in expression of specific TLRs have been reported in APCs (including an age-associated decrease in surface TLR1 in monocytes), but such decreases in protein expression alone do not appear sufficient to explain the observed findings and it is likely that both transcriptional (ie, gene expression) and posttranscriptional (eg, protein stability, modification, localization, or damage) mechanisms contribute.

Moreover, these effects are not uniform for all cell types and must be reconciled with age-related increases in circulating cytokine levels. In this regard, there is evidence for increased basal cytokine production, for example in DCs in the absence of in vitro TLR stimulation. Thus, age- associated impairment in cytokine production could reflect inflammatory dysregulation and an inability to further increase cytokine levels beyond a basal level in response to a newly encountered antigen (such as a PAMP from a pathogen or vaccine). In addition, the wide range of TLR expression

on nonblood-derived cells—including cells of epithelial, endothelial, and neuronal origin—represents an additional, largely unexplored source of complexity in the integration of TLR activity in older adults. The function of cytoplasmic PRRs in older adults remains to be definitively evaluated; however, the demonstration that “specks” of multimerized ASC and inflammasome components can be released from the cell, where they may cause extracellular inflammatory activation and activate inflammation in neighboring cells, suggests a potential source for endogenous immune activation that could contribute to an age-related inflammatory environment.

The term adaptive immunity refers to highly specific immune responses mediated by lymphocyte-specific antigen receptors: in B cells, immunoglobulins (Ig) or antibodies, which are both membrane-bound as the B cell antigen receptor (BCR) and secreted antibodies that are effectors of humoral immunity; or in T cells, the exclusively membrane-associated TCR, mediating cell-mediated immunity. Humoral and cell-mediated immunity are both characterized by immunologic memory, in which the response to previously encountered antigens is enhanced upon repeat exposure.

Both the BCR and TCR are comprised of two polypeptide chains. The BCR contains two antigen-binding sites, each comprised of one heavy chain and one light chain; the TCR contains a single a chain complexed with a ß chain that recognizes a host MHC protein bound to a peptide derived from enzymatic processing of a protein antigen on the surface of an APC (such as a monocyte, macrophage, DC, or even in some cases a B cell) (Figure 3-3).

The specificity of the humoral or cell-mediated immune response results from a highly diverse repertoire of BCRs on B cells and TCRs on T cells, respectively, that can recognize millions of different antigenic specificities. This diversity results from a lymphocyte-specific gene rearrangement program that acts on the genetic loci for Ig heavy chains or the ß TCR subunit, which contain clusters of variable (V regions), diversity (D regions), and joining (J regions), or V and J regions only for Ig light chains or the a TCR subunit. All BCR or TCR chains contain a constant or invariant region (C region). For the BCR Ig heavy chain, several different C regions are present, which denote the Ig isotype and functional implications—such as the Cµ region found in IgM, C?1-C?4 regions found in IgG subclasses, Ca found

in IgA secreted at mucosal surfaces, and Ce denoting IgE, a critical component for allergic responses or immune responses to parasitic infections. The BCR light chain locus contains two C regions, encoding sequences specific for either the ? or ? light chains.

FIGURE 3-3. Depiction of presentation of a peptide (red) resulting from proteolytic processing of a protein antigen in antigen-presenting cells (APCs) such as monocytes, dendritic cells, or B cells. The peptide is bound to host MHC protein, and this combination of peptide and class I or peptide and class II MHC is recognized by T cell receptors on CD8+ cytotoxic or CD4+ helper T cells, respectively.

The state of BCR or TCR gene rearrangement denotes specific maturation stages of B or T lymphocyte development, respectively. A rearranged Ig heavy chain or ß TCR locus contains a single V, D, and J region linked

together to form the variable region of the heavy chain or ß TCR protein, while VJ gene rearrangement is found for the Ig light chain and a TCR rearranged loci. To accomplish this, the lymphocyte-specific recombinase activating genes (RAG) mediate site-specific DNA cleavage at unrearranged V, D, and J regions. The subsequent joining of these gene segments to form a rearranged antigen receptor gene utilizes proteins responsible for DNA repair (nonhomologous end joining) that are generally expressed in all cell types as part of the response to DNA damage; such proteins include Ku70, Ku80, DNA-dependent protein kinase (DNA-PK), Artemis nuclease, X-ray repair cross-complementing protein 4 (XRCC4), DNA ligase IV, and others. Recombinatorial gene rearrangement of V regions to a more limited number of D and/or J segments, combined with imprecision in the rejoining of cleaved gene segments, results in the tremendous antigenic diversity found in B and T lymphocytes at birth (Figure 3-4). Substantial changes in this diversity occur with age, as described below.

In B cells, additional genetic steps are required for the evolution of a humoral immune response. Following gene rearrangement, an IgM BCR is generated (with surface IgM on B cells that can differentiate to a plasma cell secreting IgM with the same antigenic specificity), since the Cµ constant region is most proximal to the rearranged VDJ region. Following initial VDJ gene rearrangement and expression of a mature IgM BCR containing the Cµ constant region, a B cell–specific process known as heavy chain class switching results in the replacement of the C region exon with that of another isotype, and deletion of the intervening DNA (in this case, containing the previous Cµ region) while preserving the rearranged variable region gene.

This process is the mechanism by which evolution of the humoral immune response occurs, from initial expression of IgM early in infection to subsequent expression of IgG and other isotypes. A B cell–specific protein, activation-induced cytidine deaminase (AID), is essential for heavy chain class switching. The mechanism of heavy chain class switching is still a subject of investigation, but is facilitated by transcription at highly repetitive regions of DNA found upstream of each C region exon, termed switch regions. Current models suggest that AID targets single-stranded regions of DNA exposed by transcription, and deaminates cytosine DNA residues to induce a mutation to uracil residues. These mutations are then subjected to generally expressed DNA excision repair proteins to generate double- stranded DNA breaks, which are then repaired by similar nonhomologous

end-joining repair mechanisms utilized for VDJ recombination. The ability of AID to induce C to U mutations that are resolved by DNA repair processes also plays an essential role in another function critical to the memory B cell response—somatic hypermutation, the process by which rearranged variable region genes in mature B cells undergo additional mutation, resulting in improved affinity of the encoded immunoglobulin molecule for antigen (Figure 3-4A). Thus, mechanisms associated with maintaining the integrity of genomic DNA such as DNA repair pathways—which are likely affected by aging—play crucial roles in these fundamental processes in adaptive immunity.

FIGURE 3-4A. Depiction of DNA rearrangement events occurring in B cells. The immunoglobulin (Ig) heavy chain locus is shown. VDJ recombination is initiated by lymphocyte- specific recombinase activating gene (RAG1 and RAG2)-induced breaks at specific sequences upstream of V, D, and J gene segments, with joining of breaks using generally expressed DNA nonhomologous end joining repair proteins. D to J gene rearrangement occurs first, followed by a V to DJ gene rearrangement to yield the complete heavy chain variable region gene recognizing antigen. IgM (expressing the µ constant region gene) is first expressed during an initial antibody response, with subsequent expression of additional Ig isotypes such as IgG subtypes, IgE, and IgA resulting from class switch recombination that deletes previously expressed constant region genes in mature B cells. Somatic hypermutation also occurs in mature B cells, a process where the Ig V region undergoes mutation to enhance affinity of antigen recognition. Both class switch recombination and somatic hypermutation require the B cell–

specific protein activation-induced cytidine deaminase (AID), as well as generally expressed DNA repair proteins.

FIGURE 3-4B. Depiction of T cell receptor (TCR) gene rearrangement. The TCR ß chain genetic locus is shown. As in the immunoglobulin loci, RAG-1- and RAG-2-dependent cleavage at specific sequences upstream of TCR ß V, D, and J segments, with D to J gene rearrangement occurring first, followed by V to DJ gene rearrangement. Joining of DNA breaks is accomplished by DNA nonhomologous end joining repair proteins.

The generation of mature T cells occurs in the thymus, a bilobed organ located in the anterior mediastinum (Figure 3-5). Each lobe is comprised of a capsule, a cortex with abundant numbers of developing T cells and a deeper medulla region with sparser quantities of lymphocytes. In addition to developing T cells, several other cell types are present in the thymus to carry out crucial functions related to selection of T cells and clearance of apoptotic cells resulting from thymic selection processes (described below), such as cells of the thymic epithelium, DCs, and macrophages. The thymic cortex is colonized by early thymic progenitor cells originating from the bone marrow. Subsequent developmental steps are driven by rearrangement of TCR genes and are linked to specific regions of the thymus; in general, more mature T cell subsets are found in deeper layers of the cortex, with the most mature cells occupying the medulla. The TCR ß chain locus is the first to undergo rearrangement, with subsequent incorporation of the ß chain protein in a pre-TCR complex that signals for survival of precursors with a successful ß chain gene rearrangement. Subsequent rearrangement of the TCR

a chain genes corresponds to upregulation of both CD4 and CD8 expression (such CD4+ CD8+ cells are referred to as “double-positive” thymocytes), and if a productive gene rearrangement occurs (ie, one able to encode for an a chain protein), the mature aß TCR is expressed. These developing cells subsequently undergo so-called positive selection, in which cells bearing TCRs that recognize host class MHC class I or class II proteins survive, while those that do not undergo apoptosis. This step coincides with differentiation to “single-positive” CD4+ cells recognizing MHC class II proteins, and cytotoxic CD8+ T cells recognizing MHC class I. Another process of negative selection eliminates those T cells carrying aß TCRs with high affinity for self-peptide/MHC complexes that could result in autoimmunity. Additional lineage specification for development of regulatory T cells (Treg), which inhibit T cell activation, and ?d T cells expressing two distinct classes of TCR proteins that may play a role in the recognition of lipid antigens, also occurs in the thymus (Figure 3-6).

FIGURE 3-5. Histologic examination of the thymus in a child (left) and adult (right). The thymic capsule (C) is indicated, with the thymic cortex (Co) (which is initially colonized by T cell progenitors originating in the bone marrow) and medulla (M) (containing mature T cell subsets) indicated. With age, marked thymic involution occurs, with increased replacement of thymic

epithelium with adipose tissue (A). (Reproduced with permission from Mescher AL.

FIGURE 3-6. Overview of T cell development. T lymphopoiesis is closely linked to the state of T cell receptor gene rearrangement in the thymus, with initial ß chain gene rearrangement followed by TCR a chain gene rearrangement in T cell precursors expressing both CD4 and CD8 (“double-positive” T cells). Following expression of a TCR on the cell surface (indicated in red), positive selection (+ selection), which selects for survival of T cells bearing TCRs that recognize host MHC class I or class II, and negative selection (– selection), which deletes potentially autoreactive T cells, occur in single-positive T cells (Single [+]) expressing CD4 or CD8.

TABLE 3-3 ¦ AGE-RELATED CHANGES IN THE ADAPTIVE IMMUNE SYSTEM

begins to decrease in size and cellularity in childhood. The thymic epithelium begins to diminish, particularly after puberty, and is replaced by adipose tissue that may be a source of cytokines and chemokines that interfere with thymopoiesis (Figure 3-5). The T cell generation capacity of the thymus is substantially diminished by young adulthood, to around 10% of the capacity seen in infancy. T cell lifespan can be assessed by in vivo metabolic labeling, and the generation of new T cells may be measured via the detection of T cell receptor excision circles (TRECs), the excised products of VDJ recombination of DNA that are only detectable in recently matured T cells, since they cannot undergo replication and are diluted by cell division.

Such analyses have revealed minimal thymic activity in older adults, and indicate that maintenance of the T cell pool occurs instead via cell division and expansion of preexisting T cells. Not surprisingly, this absent thymic activity results in decreased numbers and proportion of naïve (CD45RA+) T cells in peripheral blood, with an increase in T lymphocytes with a memory phenotype (CD45RO+). In this regard, it is notable that a T cell phenotype

resembling that seen in aged adults was found in young adults who had undergone thymectomy in childhood. The mechanisms underlying thymic involution remain a subject of active study; alterations in thymic epithelial cells that facilitate the developmental expansion and selection steps of T cell development, such as changes in expression of the master transcriptional regulator FoxN1, are thought to play an important role. There is interest in developing interventions that can stabilize or reverse thymic involution and thereby improve T cell production in older adults. However, the widespread conservation of thymic involution in most mammals raises the speculative question of whether it might represent an evolutionary adaptation, perhaps protecting the host from lymphocytic malignancies in older age.

Influence of CMV infection on T cell repertoire The lack of generation of new (naïve) T cells in older adults as a result of thymic involution also results in marked changes in the diversity of the TCR repertoire, which decreases substantially with age. Notably, cytomegalovirus (CMV) infection is associated with such profound alterations in diversity (Figure 3-7). Like other herpesviruses, following primary infection CMV establishes a state of latency in the host, with reactivation to productive infection throughout life, often in the setting of stress or non-CMV–associated illness that is usually asymptomatic and not associated with CMV-dependent end organ disease.

CD4+ and CD8+ memory T cell populations, and resultant decreases in TCR diversity with expansion of nonmalignant T cell clones—many of which recognize CMV peptides. Such oligoclonal T cell expansions may comprise a large proportion (even in some cases the majority) of CD4+ or CD8+ T cells, and are also found in CMV seronegative older adults; in such individuals, it is likely that other herpesviruses associated with latent infection, such as EBV or HHV-6, other viruses such as hepatitis C virus, or other sources of chronic immune system activation may contribute to loss of repertoire diversity. Notably, the extent of diversity loss has been linked to decreased lifespan in older adults, though the underlying mechanisms or associated factors remain incompletely understood.

FIGURE 3-7. A. Graphical depiction of age-associated decrease in naïve T cells and increased proportion of memory and effector T cells, reflecting thymic involution and proliferative expansion of preexisting T cells. B. Flow cytometric plots of CD28 expression (Y-axes) versus expression of CD45RA (a marker of naïve T cells) in CD8+ T cells from representative young and older subjects stratified by CMV seroreactivity. Note the increased proportion of CD8+ T cells expressing low or absent levels of CD28 and decreased proportion of CD45RA expressing naïve T cells in older adults; these changes are enhanced in CMV-seropositive older adults. (Modified with permission from Almanzar G, Schwaiger S, Jenewein B, et al. Long-term cytomegalovirus infection leads to significant changes in the composition of the CD8+ T-cell repertoire, which may be the basis for an imbalance in the cytokine production profile in elderly persons. J Virol. 2005;79[6]:3675–3683.)

Aging and alterations in T cell phenotype and signal transduction The age-related increase in memory phenotype T cells, with decreased naïve T cells is also associated with several additional findings. For example, aged human T cells show a substantial loss of expression of the costimulatory protein CD28 from the surface of CD8+ cytotoxic T cells (Figure 3-7). CD4+ T cells show a

much lesser degree of CD28 loss with aging, although marked increases in CD4+ CD28- cells can be found in adults with rheumatologic disease. CD28 associates with ligands (CD80 and CD86) on the surface of APCs such as activated macrophages or DCs, and this interaction provides a second signal, in addition to that provided by the TCR interaction with peptide bound to host MHC, that is critical for optimal T cell activation. Thus, this loss of CD28 would be expected to influence T cell activation in CD8+ T cells.

In this regard, signal transduction by the TCR is also diminished in the context of aging—in general, nonreceptor tyrosine kinase–dependent pathways downstream of the TCR are inhibited in T cells from older adults, with potential mechanisms for impaired signaling including increased expression of phosphatases that are negative regulators of MAP kinase– dependent signaling. Though the mechanisms underlying diminished signaling in human T cells remain incompletely understood, both cell-intrinsic mechanisms, such as mitochondrial dysfunction in T cells resulting in increased levels of reactive oxygen species (ROS), and cell-extrinsic mechanisms, such as the inhibition of TCR signaling and engagement of inhibitory cytokine signaling pathways (such as the suppressor of cytokine signaling [SOCS] proteins) resulting from increased systemic levels of TNF- a and other cytokines, appear to be important contributing factors.

It is likely that such signaling alterations may differ among different T cell populations and lineages to extend beyond the dichotomy of CD8+ and CD4+ T cells to CD4+ T cell subtypes. These include TH1 helper T cells, which develop in response to IL-12 produced by activated APCs and the transcriptional regulator T-bet to produce interferon-? and facilitate intracellular immunity against bacteria, viruses, and fungi; TH2 helper cells developing in response to the GATA3 transcription factor that produce IL-4, IL-5, and IL-13 and mediate allergic and antiparasitic T cell responses; TH17 cells, a heterogeneous lineage in humans that are named for their production of IL-17 and are associated with inflammatory responses in the context of bacterial and fungal infections, autoimmunity, and malignancy; follicular helper T cells providing critical help for B cells in lymphoid follicles of lymph nodes and other secondary lymphoid organs; regulatory T cells (Treg) expressing the FoxP3 transcription factor that inhibit immune responses; and resident memory T cells (TRM) present in specific tissues or organs such as lung, skin, or gut that do not recirculate and appear critical for rapid

responses to pathogens (both Treg and TRM cells may be either CD4+ or CD8+ single positive). The functional consequences of aging on these human T cell subsets remain incompletely understood, but are likely to be complex; for example, current evidence suggests that human CD4+ and CD8+ Treg cells are found in increased numbers in the blood of older, compared to young adults, but the ability to induce Treg cell development (particularly CD8+ Treg cells) with cytokine treatment is diminished with age. The consequences of these opposing effects on the regulation of T cell responses remain to be determined.

In contrast to T lymphopoiesis, where T cell progenitors migrate from the bone marrow to the thymus, B cells arise from HSC that differentiate to a common lymphoid progenitor. However, as with the T cell lineage, antigen receptor gene rearrangement (in this case, of immunoglobulin [Ig] heavy and light chain genes) is intimately linked to B cell development, with Ig heavy chain gene rearrangement occurring in early B cell progenitors (pro-B cells). The Ig heavy chain protein in conjunction with an invariant surrogate light chain protein forms the pre-B cell receptor complex that links to signal transduction pathways to mediate expansion and progression to the pre-B cell stage, when light chain gene rearrangement occurs to generate the mature Ig BCR (Figure 3-8). Through this process, a library of B cells is developed with a repertoire of millions of specificities. Notably, an incompletely understood mechanism of negative selection occurs in the B cell lineage (as in the T cell lineage) by which B cells expressing potentially autoreactive BCRs are deleted both in the bone marrow and in peripheral lymphoid tissues.

FIGURE 3-8. Depiction of B cell development. Immunoglobulin gene rearrangement (first of the heavy chain genes, followed by light chain gene rearrangement) is crucial to B lymphopoiesis, resulting in generation of a library of mature B cells collectively expressing a highly diverse repertoire of surface immunoglobulin (the B cell antigen receptor). Encounter with a specific antigen results in expansion of a clone of B cells recognizing that antigen, and generation of memory B cells and plasma cells secreting immunoglobulin of the same specificity.

Dramatic effects of aging on B cell development are found in mouse models; however, human B lymphopoiesis in the bone marrow appears generally preserved with age, although the total number and percentage of B cells diminish in the blood of older compared to young adults. Moreover, B cell production of antibodies in response to infection or vaccination is impaired with age, and is associated with diminished production of antibody-secreting B cells termed plasmablasts, which generally appear approximately 7 days following immunization. In part because of the use of varying definitions of B cell subsets, it has proven difficult to determine whether, as in the T cell lineage, memory B cells are expanded with age. Notably, the proportion and number of memory B cells that have undergone heavy chain class switching do decrease with age; it is likely that age-associated alterations in T cell function contribute to such differences, since B cell responses are intimately associated with helper T cell activity. However, B cell–intrinsic changes have been identified in older adults, such as the decreased expression of AID (essential for heavy chain class switching—Figure 3-4A) in B cells from older adults that is linked to decreased levels of the E47 transcription factor. Though age-related developmental changes in the B cell lineage remain completely understood, functional alterations are manifested for example by the age-associated increase in monoclonal gammopathy, which has been

estimated to affect as many as 3% of adults 50 years or older and 5% of adults 70 years or older. In addition, titers of autoantibodies such as rheumatoid factor are generally increased with age, suggesting additional dysregulation and in particular, possible alterations in the negative selection steps mediating deletion of autoreactive B cell clones. The persistence of autoreactive B cell clones may also be reflected in age-related changes in the B cell repertoire; repertoire diversity appears to be diminished with age, with marked increases in nonmalignant clonal expansions of B cells. As with T cells, there is evidence that such expansions could be associated with the control of reactivation of chronic herpesvirus infections with CMV or EBV. In addition, profound loss of B cell repertoire diversity has been associated with alterations in health or functional status, such as frailty; the effects of functional alterations or multimorbidity on the immune system in older adults is an emerging area of significant research and clinical interest.

Impaired responses to vaccines represent perhaps the clearest examples of the consequences of immunosenescence, and have important clinical consequences reflected in the increased susceptibility to infectious diseases found in older adults. Mechanisms discussed in this chapter contribute to this impaired response, but multiple additional host factors including gender, age- associated changes in body composition (eg, changes in adipose tissue), and associated comorbid medical conditions or medication use all contribute.

Here, we provide an overview of three vaccines—against influenza, VZV, and Streptococcus pneumoniae—currently recommended for older adults and briefly discuss vaccines against SARS-CoV-2 infection.

Over 90% of the approximately 30,000 annual deaths from influenza in the United States occur in adults 65 years or older, and older adults are at increased risk for morbidity arising from complications of influenza, such as viral pneumonia or bacterial superinfection. Although the incidence of influenza infection decreased substantially with the advent of SARS-CoV-2 disease, it is virtually certain that influenza outbreaks will resume following the pandemic. The seasonal vaccine in wide use is an inactivated vaccine containing defined doses of the hemagglutinin (HA) protein, one of the surface glycoproteins of the influenza virus; anti-HA antibodies are

associated with protection against disease. However, because of a high mutation rate in the HA protein, the composition of viral strains in the vaccine is adjusted annually based on surveillance of circulating strains. Currently, four (quadrivalent) influenza strains are present in the vaccine, with two influenza A strains (typically one H1N1 and one H3N2 subtype) and two B strains.

The efficacy of the standard dose seasonal influenza vaccine in older adults has been estimated at approximately 40% for the prevention of an influenza-like illness, and approximately 60% for confirmed influenza, and is lower in older individuals with increased comorbid conditions (such as residents in long-term care facilities). Demonstration of a mortality benefit for influenza vaccination has proven to be difficult; it has been hypothesized that many studies may be influenced by selection bias in which a subset of frail adults who are undervaccinated because of poor health disproportionately contribute to mortality from influenza. However, a history of revaccination, as opposed to first vaccination against influenza, has been associated with decreased mortality in at least one study.

Evidence for poor vaccine efficacy, combined with the demonstration of impaired antibody responses to vaccination reflected in decreased levels of antibody-producing cells following influenza immunization have led to interest in alterative vaccine formats to improve response in older adults.

Both the live attenuated influenza vaccine, which uses a cold-adapted virus that replicates in nasal mucosal tissues (at lower temperature than in the lungs) to establish immunity, and an intradermal influenza vaccine that utilizes the immunologic milieu of the skin (which contains APCs including Langerhans cells) that is bypassed by intramuscular vaccination, have shown efficacy in older adults; in fact, antibody titers to influenza viral vaccine strains were higher in older adults given the intradermal preparation versus standard intramuscular vaccine in at least one study. However, at present, these formats are not approved for adults age 65 and older. A high-dose trivalent influenza vaccine containing four times the dose of HA protein for each vaccine strain was approved for adults age 65 and older in 2009, and is now available in a quadrivalent format. Several studies have shown equivalent or increased antibody titers to vaccine viral strains compared to standard dose vaccine in studies enrolling older adults, and a randomized comparing standard to high-dose vaccine in nearly 32,000 older adults revealed a modest benefit for the high-dose vaccine (with a 24% relative

efficacy for prevention of influenza-like illness compared to standard dose vaccine). A second vaccine approved for use in adults 65 years and older is a standard-dose quadrivalent vaccine combined with MF59, a squalene- derived adjuvant that appears to enhance antigen presentation. A cluster- randomized trial comparing the MF59 adjuvanted vaccine to unadjuvanted, standard-dose vaccine in 823 nursing homes revealed a 17% reduction in suspected or laboratory-confirmed influenza outbreaks and a 20% reduction in hospitalization for pneumonia or influenza for the adjuvanted vaccine.

Ongoing work to further improve influenza vaccines includes the use of adjuvants, including those activating the innate immune system such as TLR agonists. An additional research direction is the development of a “universal” influenza vaccine, which would not require annual revision. The immune response to current HA-based vaccines is dominated by antibodies to the highly variable head region of HA; approaches to a universal vaccine include the use of viral antigens that are highly conserved across influenza strains, such as the HA stalk region or neuraminidase protein. Such vaccines are in early clinical trials, and their efficacy in elucidating strong immune responses in older adults remains to be studied. Finally, biochemical pathways implicated in vaccine response may be pharmacologically modulated to enhance vaccine protection. An example of this possibility came from the demonstration in a placebo-controlled trial that low doses of the immunosuppressive agent rapamycin enhanced antibody response to influenza vaccination by about 20% in older adults. This study implicated the mechanistic target of rapamycin (mTOR) pathway, which is inhibited by rapamycin, in vaccine response. Notably, in addition to its effects on T cell signal transduction (relevant particularly for prevention of transplant rejection), rapamycin administration to mice late in life resulted in significant lifespan extension (14% for female and 9% extension for male mice). These increases in lifespan and vaccine response are principally mediated by the TOR complex 1 (TORC1) protein complex downstream of mTOR, which appears crucial for nutrient sensing and activation of protein translation. Additional studies utilizing catalytic and allosteric inhibitors of mTOR that selectively inhibit TORC1 showed not only improved influenza vaccine response, but also decreased rates of respiratory tract infections over a 1-year period (after only 6 weeks of treatment with the mTOR inhibitor cocktail). These studies suggest the promise of enhancing age- associated impairment in immune responses to promote improved vaccine

response or host defense against infection. In this regard, early clinical trials of so-called senolytic agents that induce apoptosis of senescent cells are in progress; one combination being tested is the combination of the tyrosine kinase inhibitor dasatinib and the flavonoid quercetin. Another candidate agent that may improve immune responses in older adults is metformin, an oral hypoglycemic agent with pleiotropic effects that result mainly from its activity as an AMP kinase activator, with inhibition of TORC1, decreased oxidative stress resulting from inhibition of complex I of the mitochondrial electron transport chain, and decreased age-related chronic inflammation through inhibition of the transcription factor NF-?B. The upcoming TAME (Targeting Aging by Metformin) trial represents a new paradigm for clinical trials in specifically targeting aging phenotypes; improving age-related deficits in immune response will be an important direction for these and other future trials designed to improve human health span (Figure 3-2).

Herpes zoster (shingles), resulting from reactivation of VZV, frequently affects older adults—usually manifesting as a painful cutaneous vesicular eruption in a dermatomal distribution that could also present as multidermatomal or disseminated zoster in the setting of immunosuppression or malignancy. The incidence of herpes zoster increases markedly with age, and the CDC estimates that approximately one-third of Americans will have an episode of zoster infection during their lifetime. Studies in immunosuppressed adults have established that defects in T cell immunity, like those associated with aging, are essential for maintaining VZV in a state of latency in ganglia associated with peripheral and cranial nerves—although the precise mechanisms involved in maintaining VZV latency remain incompletely understood. Notably, studies to quantify VZV-specific CD4+ T cells have revealed that approximately 30% to 40% of adults 55 years and older have no detectable CD4+ VZV responses, a potential correlate for the increased risk of older adults for zoster infection; in an effort to boost this defective cell-mediated immunity the first-generation zoster vaccine (Zostavax) was a live attenuated viral preparation containing 10- to 40-fold higher viral plaque forming units compared to the VZV vaccine given to prevent primary infection in childhood. Based on a large placebo-controlled efficacy trial enrolling over 38,000 adults age 60 and older, the vaccine reduced the incidence of zoster by 51%, but a substantial decrease in

efficacy was seen as a function of age: protection against zoster was estimated at 64% in individuals 60 to 69, 41% for those 70 to 79, and 18% for individuals over 80. This reduced efficacy in adults 70 years and older, limited the utility of the vaccine, particularly as it became clear that repeat vaccination would be necessary to maintain protection against shingles outbreaks. This first-generation vaccine is no longer available in the United States, and has been replaced by a second-generation, recombinant vaccine (Shingrix) containing VZV glycoprotein E and the AS01B adjuvant consisting of monophosphoryl lipid A (a TLR4 agonist) complexed with a saponin derivative (QS-21) in liposomal form. This vaccine reduced the incidence of shingles by 97% in a trial of adults 50 years and older and by 90% in a second trial of adults 70 years and older. This last trial also found an 89% decrease in the incidence of postherpetic neuralgia. In contrast to the first- generation live attenuated vaccine, no age-related decrease in efficacy was reported for this second-generation vaccine, suggesting that the AS01B adjuvant could potentially overcome age-related alterations in vaccine- immune response and would be a candidate for use in other vaccines used in older adults.

Adults 65 years and older and children under age 2 are at greatest risk for the development of invasive pneumococcal disease (eg, bacteremia, endocarditis, meningitis), but the highest mortality rates (of 15%–20%) are found in adults 65 years and older. For decades, vaccination against

Streptococcus pneumoniae utilized the 23-valent polysaccharide vaccine, which contains purified pneumococcal capsular polysaccharides from 23 (of at least 90) strains that are commonly associated with infection in the United States. In most studies, this polysaccharide vaccine appears to reduce the risk for invasive pneumococcal disease, but at the same time most studies have not shown a benefit for this vaccine in prevention of noninvasive disease (such as pneumococcal pneumonia) or all-cause pneumonia in older adults. From an immunologic perspective, the polysaccharide vaccine is generally considered to be a so-called “T-independent” vaccine, as the pneumococcal polysaccharides stimulate B cells directly, inducing activation and differentiation to antibody-secreting cells. While it appears possible that some T-dependent responses may arise from this vaccine (for example from copurifying pneumococcal protein components in the vaccine), there remains

concern regarding the potential defect in T cell–dependent immunologic memory—a potential limitation given the importance of the memory response in facilitating more rapid responses mediated by higher affinity antigen receptors resulting from processes such as somatic hypermutation in B cells.

For this reason, pneumococcal conjugate vaccine offered the possibility of improved efficacy, since in these vaccines polysaccharides are conjugated to a carrier protein, CRM197—a nontoxic mutant of diphtheria toxin. This step allows the polysaccharide conjugate to undergo antigen processing for presentation in the context of host MHC to T cells, allowing a full memory response to be generated (with the resulting generation of memory B and T cells). While T cell function and memory responses are clearly diminished in older adults (as discussed above), there is biological plausibility to the hypothesis that immunologic memory, even diminished, is preferable to a complete absence of memory. The CAPiTA study specifically evaluated the 13-valent conjugate pneumococcal vaccine in a randomized, placebo- controlled trial of more than 80,000 adults 65 years and older in the Netherlands who had never previously received a pneumococcal vaccine.

The conjugate vaccine was found to diminish the risks of both noninvasive and invasive pneumococcal infection arising from vaccine-related strains, and the protective effect extended for the duration of the study (~4 years). While this was the first study to show a benefit to vaccination in decreasing the incidence of pneumococcal pneumonia, it remains unclear whether a similar benefit for older adults in the United States would be found. Because the CAPiTA trial began in the Netherlands prior to the general use of conjugate vaccine in Dutch children, it has been speculated that the benefits of vaccinating older adults may be less clear in the United States, where the general use of pneumococcal conjugate vaccine in children has led to a substantial decrease in invasive disease in older adults. Currently, the 23- valent polysaccharide vaccine remains the mainstay of recommendations for the prevention of pneumococcal disease in older adults, while for adults with immunocompromising conditions a series of vaccination with the 13-valent conjugate vaccine followed by the polysaccharide vaccine in 8 weeks or later is suggested. However, newer generation conjugate vaccines with increased numbers of strains may further modify these recommendations for older adults.

As with other infectious diseases, the COVID-19 pandemic has had a disproportionate impact on older adults, with approximately 80% of deaths from COVID-19 occurring in adults 65 years and older; outbreaks in nursing homes have been particularly devastating, and it is estimated that nearly 1 in 10 nursing home residents in the United States died of COVID-19 during the pandemic. The specific immunologic mechanisms contributing to COVID-19 pathophysiology in older adults remain an area of active investigation; however, many aspects of the aging immune system appear to be manifested in COVID-19, such as increased levels of proinflammatory cytokines such as IL-6 and TNF-a, alterations in innate immune activation such as those responsible for the type I interferon response, and expansion of activated T cell populations with features of terminal differentiation. Such studies in patients with COVID-19 are challenging to interpret because of substantial heterogeneity resulting from differences in treatment regimens, comorbid medical conditions, and variability in timing of sample acquisition relative to disease course, and this remains an active area of investigation.

The first vaccines against SARS-CoV-2 to show efficacy in older adults were RNA vaccines—BNT162b2 and mRNA-1273—both containing messenger RNA (mRNA) encoding the full-length SARS-CoV-2 spike protein, with specific nucleoside modifications to minimize activation of host innate immune PRR pathways recognizing RNA. Such mRNAs were packaged in a lipid-containing nanoparticle, and upon intramuscular administration are translated in the cytoplasm of host cells to generate

SARS-CoV-2 spike protein. Both vaccines elicit spike protein-specific neutralizing antibody and T cell responses, and initial data indicate excellent efficacy (92% for BNT162b2 and 86% for mRNA-1273) in adults 65 years and older. Additional vaccine platforms are also likely to find clinical use, using replication-deficient adenoviral-based vectors and recombinant protein vaccines. Many unanswered questions remain for all of these vaccines, such as duration of protection for B and T cell–dependent immunity, need for repeat of vaccinations/booster doses, and protection against emerging SARS- CoV-2 variants.

Understanding of the mechanisms underlying age-associated immune dysfunction has implications not only for morbidity and mortality from infectious diseases and vaccine response, but also for the age-related

increase in malignancy (perhaps reflecting age-related changes in tumor surveillance and DNA repair or genome stability) and for emerging fields of research such as wound healing and organ transplantation. Studies of immune system aging have begun to utilize multidimensional data from whole-genome analyses of gene expression, including evaluation of small microRNAs whose expression has been implicated in the regulation of many genes. The analysis of age-related epigenetic changes, such as methylation or histone modification, that are linked to the regulation of gene expression has also advanced and will soon be routinely done at the single-cell level. In addition, the emerging interface of immunity and metabolism, as manifested for example by mitochondrial alterations or engagement of the mTOR pathway, suggests the utility of metabolic pathway analyses (metabolomics) using mass spectroscopy platforms. Immunologic studies increasingly will also include high dimensional data from mass cytometry (CyTOF) platforms that should be able to substantially exceed the number of analytic channels available using conventional flow cytometry. An additional area of ongoing research will evaluate the components of intestinal commensal organisms (the intestinal microbiome) or those at other tissue sites, and their interaction with the immune system in modulating inflammation, metabolic activity, and other parameters; initial studies have already found age-related differences in content of the intestinal microbiome that are associated with factors such as nutritional status, diet, and functional status such as frailty. In view of the high degree of heterogeneity found in older adults, encompassing medical comorbidities, medication use, as well as gender and race, future research on the aged immune system should provide new biological insights into how this heterogeneity is translated into changes in functional status—with the hope of identifying methods to improve quality of life in older adults.

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As people age they experience changes in physical and cognitive capacities, such as gait speed and reaction time, and also changes in emotional experience and social interests. Cultures impose an order on this continuum of change in widely shared understandings of the life course, which partition the lifespan into different stages. One of the most famous is Shakespeare’s seven ages of man (As You Like It, II, 7). The Elizabethan stages of life include infancy, “whining school boy … creeping unwillingly to school,” lover, soldier (“seeking the bubble reputation even in the cannon’s mouth”), judge, and then two stages of decline: initial loss of capacities (“big manly voice, turning again toward childish treble”), and finally “second childishness and mere oblivion … sans teeth, sans eyes, sans taste, sans everything.” Other cultures are more charitable in their ideas about advanced age. The Samia people of Kenya describe old age as a pleasant time to sit before the fire and be fed. Such differences in thinking about the life course remind us that psychosocial aging is governed both by biological and sociocultural elements. A major focus of developmental approaches to psychosocial aging is to distinguish between invariant biological change and cultural constructions that selectively emphasize particular transitions across this continuum of change.

There is no single age at which we can say that people cross the threshold into “old age” and become an “older adult.” People age at different rates; hence, for any given age, there will be great variation in proposed

biomarkers of aging or phenotypes of healthy aging. In the United States, establishment of the Social Security system linked old age to age 65, but research on the start of aging and its pace suggests that adults with the same chronologic age differ in proposed aging biomarkers and that accelerated aging may have social determinants, such as experience of adverse childhood events and poverty.

But people do have an idea of when they become old. A number of surveys have asked at what age someone is old. The start of “old age” can be assigned to a wide range of chronological ages. Choices of an age for “old age” tell us the decade when people are expected to slow down, retire, and focus on self-maintenance rather than new careers or goals. Figure 4-1 shows the age at which respondents consider women to be old. These data are drawn from the National Council on Aging Myths and Realities of Aging survey, conducted in 2000. The data are weighted to reflect the sampling scheme and overrepresentation of older people and minorities. The figure plots the mean age “the average woman” is said to be “old” by respondent’s age and sex.

FIGURE 4-1. Reported age women are “old,” United States, 2000. (Data from National Council on Ageing.)

Key Clinical Points

Lack of support (social isolation and loneliness) has a negative effect, and social engagement (volunteering, lifelong learning, and involvement in intergenerational programs) has a positive effect, on health and well-being in old age.
Social environments that promote aging in place support psychosocial health.
The aging services network is important in promoting engagement across diverse domains.
Hospice and palliative care promote involvement of older people in decision making at the end of life and the psychosocial health of family caregivers.

Note the strong relationship between the survey respondent’s age and his or her report of when women are old. Young people consider the start of old age to be much earlier than older people. For people around age 20, women become old at age 45 or 50. By the time respondents reach their sixth or seventh decades, old age is pushed back to the late 60s and early 70s. Note the strong gender difference in reports of when a woman is old. Female respondents date the start of old age to a later age than men, whatever the respondent’s age. Women consider old age to begin 2 to 4 years later than

men. These differences suggest a need to consider social elements when examining perceived age-related changes.

The relevance of social or cultural factors in conceptions of the life course is evident in the “infantilization” of older adults, such as use of baby talk or saccharine language applied to frail or very old people. Cognitive anthropological studies show that cultural dimensions, such as productivity, vulnerability, and reproductive potential, underlie judgments of “young,” “middle-aged,” and “old.” In one study, respondents were asked to group hypothetic age-linked social statuses according to similarity.

Multidimensional scaling analyses revealed that respondents grouped old people and children together as opposed to people of middle age. This cultural logic may explain why baby talk is often applied to older people with cognitive impairment or other disabilities and terms typically reserved for children are often applied to older people. The reverse is also true: younger adults who are not active, not interested in new experiences or travel, not willing to switch careers, or who are slow, deliberate, or risk averse, are often called “old” or “old before their time.” We are enjoined “to act our age.”

Even this brief discussion of the use of age criteria to label behaviors suggests that attitudes toward aging and old age are mostly negative. Old age is usually seen as a time of decline, withdrawal, vulnerability, and even reversion to childhood. In this view, aging is not welcome and little should be expected of older people, except perhaps to ease decline, provide care, and protect people from exploitation or danger related to their increased vulnerability. These are the elements of “ageism”: assumptions of disability or vulnerability (and hence need for protection) based on age, rather than actual competencies. A goal of developmental approaches to psychosocial aging is to avoid such oversimplifications and cultural biases to determine the range of changes in social, affective, and cognitive experience associated with aging.

Understanding the role of psychosocial factors in late life requires that we first take a high-altitude view of human development to identify the basic biological and social forces that fundamentally shape the development of people as they age and the ways they respond to challenges associated with aging. These forces are typically viewed as constraints and can be briefly summarized in four propositions.

Although there is considerable interindividual variability in biological development, overall biological resources across the lifespan resemble an inverted U-function. During childhood and adolescence, cognitive and physical abilities increase and provide the basis for the development of complex motor and cognitive skills. Physical development plateaus during adulthood and then later declines. Cognitive function, especially “fluid” capacities, decline in old age even apart from dementing disease.

Second, societies impose age-graded structural constraints on development. Lifespan psychologists and sociologists emphasize that all societies impose age grades. These roles provide predictability and structure at both individual and societal levels. A prototypical case is childbearing in women, which is shaped by both social institutions and biological constraints.

Third, life is finite. Whatever is to be achieved or experienced in life has to be done in a limited period of time, typically fewer than 80 to 90 years. At any given point in an individual’s life, the anticipated amount of time left to live may shape behavior and affect in important ways.

Fourth, genetic endowment is a limiting factor on biology and behavior. Although the potential behavioral repertoire of humans is vast, function in a given domain is often constrained by genetic makeup.

In this view of development, the accumulated resilience or adaptive capacity of individuals will vary as a function of the individual’s location in the life course. Behavioral resources and psychological reserves may be greater at older ages because of accumulated life experiences, acquisition of skills, and increased knowledge. The type and intensity of biological pathways activated by stressful encounters as well as the manifestation of overt disease will also vary as a function of the individual’s position in the life course.

Psychosocial aspects of aging are involved in changes in many domains, including work, retirement, residence, sexuality, stress, widowhood, emotion, mental health, social support, and friendship, to name just a few. A broad conceptual framework identifying key psychosocial factors is presented in Figure 4-2. At the far left, the model identifies a broad array of sociodemographic characteristics that directly and indirectly shape individual development, quality of life, and health throughout the life course. For example, many of the health disparities in our society, such as differences in life expectancy or risk of low birth weight, have been linked to socioeconomic status (SES), race and ethnicity, and gender.

Environmental and social resources and constraints include multiple indicators known to affect health outcomes, including physical and social characteristics of environments. Discrimination, negative life events, and

existing comorbidities can be major sources of constraint, while religious involvement and social support are often important protective resources.

Psychological influences include positive factors, such as optimism, self-esteem, mastery, and control, as well as negative effects, such as depressive symptoms and perceived stress. The effects of psychological and social/environmental factors on health are mediated by health behaviors and biological pathways, such as the central nervous system and endocrine response. Although the causal links between these groups of variables are still debated (hence no arrows are shown in the figure), all are clearly important contributors to health and quality of life.

Biological changes are relevant to psychosocial aging. Late-life depression (LLD) may stem from inflammatory and hormonal abnormalities. LLD is often associated with greater chronicity, relapse, resistance to treatment, and suicide risk, as compared to depression in younger adults. It may also be comorbid with dementia and hence points to the need to evaluate cognitive status. In women, the perimenopausal transition, but not necessarily the postmenopausal stage, can be associated with depression, resulting from declining and fluctuating estrogen levels. Among people undergoing chronic stress, chronically elevated serum cortisol can generate a proinflammatory milieu and accelerate the aging process, a phenomenon known as

Age-related decline in melatonin secretion from the pineal gland at night may explain sleep disturbances among older adults. Poor sleep hygiene may contribute to increased irritability, poor mood, and elevated dementia risk in this population. The declining functional status of organ systems associated with the aging process, including, for example, diastolic heart failure, may limit activities and therefore socialization. Reduced vision and hearing may also contribute to reduced social interaction.

Purposeful efforts at social engagement may aid in dementia prevention by maintaining brain cellular integrity before gross atrophy sets in. Recent research has shown that greater social engagement among older adults is associated with greater microstructural integrity of brain cells.

In highlighting core psychosocial factors and mechanisms linked to health and well-being, we discuss four psychosocial domains—social integration, stress, personality, and affect—that are critical to understanding health and quality of life in old age.

Social integration is the degree to which an individual is involved with others in a larger community. Maintaining social relationships is critical to the health and well-being of older adults. Involvement in satisfying relationships is associated with physical health, including, for example, decreased risk of cardiovascular disease, functional decline, and mortality. Positive social interactions further support the psychological well-being of older adults through helping them maintain meaning in life, and such interactions are also associated with increased sense of life satisfaction and happiness.

When attempting to understand the mechanisms by which social support affects health and well-being, there are two potential explanations. One, the buffering hypothesis, suggests that social ties and social support promote health by acting as buffers to the effects of life stressors and negative events. Another is the direct effect hypothesis, which suggests that social ties and social support have a positive impact on health apart from stress. By the same token, negative social interactions may have detrimental effects on health and well-being.

It is important to consider the composition of social networks, which includes the number of family members, friends, neighbors, and acquaintances, and the density of social ties. Research indicates age differences in the size and composition of social networks, with networks shrinking at greater ages. A countervailing force is the larger proportion of well-known social partners in these smaller networks. According to socioemotional selectivity theory, discussed later, these changes serve an emotional regulatory function for older adults. Smaller networks with well- known social partners allow older adults to increase predictability in social interactions and maximize positive and minimize negative interactions.

Based on this theory, the smaller size of networks in old age, therefore, does not necessarily indicate lack of support but may instead serve a protective function.

Research suggests that a low level of social activity and social contacts is associated with poor functional outcomes. Loneliness, or perceived social isolation, may be most important for health effects. Population-based studies show that loneliness is associated with increased morbidity, including cardiovascular illness, coronary heart disease, and depressive symptoms, as well as mortality. Loneliness has also been associated with personality disorders and psychoses, suicide, impaired cognitive performance and cognitive decline over time, and increased risk of Alzheimer disease.

Interventions that address social isolation, such as programs that enhance social skills, provide social support, or increase opportunities for social interaction, reduce isolation; but successful interventions may also need to address maladaptive social cognition through cognitive behavioral therapy to reframe perceptions of loneliness and personal control.

The intergenerational solidarity paradigm is a common model for assessing intergenerational relations in the context of aging families. The intergenerational solidarity paradigm includes seven dimensions:

The widely held belief that contemporary families do not provide care for their aging members has been disproved by years of research. In fact, families continue to be the mainstay of long-term care and social support to older adults. While the majority of older adults in the United States live in independent households, older adults rely on children when they need support. Policymakers consider families the key source of support for meeting the growing needs of the older population. While spouses, mainly wives, provide most family caregiving support, adult children provide the bulk of care when a spouse is absent or unable to care.

Four forms of support are exchanged across generations: (1) emotional support: the expression of empathy, caring, concern, and love; (2)

instrumental support: provision or direct assistance in instrumental activities (eg, transportation, shopping, cooking, cleaning, yard work, and house repair) or personal self-maintenance care, such as help with bathing, dressing, and feeding; (3) informational and organizational support: support in decision making, care coordination and management, and financial management; and (4) financial support: income transfers.

However, receiving instrumental support may have a mixed effect on functional status. Greater frequency of instrumental support may increase the risk of subsequent disability. Furthermore, receipt of instrumental support may lead to feelings of helplessness, perceptions of low mastery and autonomy, and reduced self-efficacy and sense of control.

The extent to which support is given, received, or exchanged between adult children and aging parents depends on several factors, some related to the adult children, others to the aging parents, others to the relationship between adult children and aging parents, and still others to the larger contexts governing relationships. Figure 4-3 displays the many factors involved in predicting parental support, described here.

FIGURE 4-3. Conceptual framework for understanding factors affecting parental support.

Characteristics of the adult child Findings regarding gender differences in filial norms toward older parents are mixed. While sons and daughters seem equally committed to provide care to aging parents, gender differences are apparent for specific types of support. Adult sons are more likely to provide financial and instrumental support, while adult daughters are more likely to provide personal care, complete household chores, and offer social support.

Another predictor is income or more generally, social class, as it affects both the need and the availability of support. Financially and educationally advantaged families can more easily purchase care on the private market, thereby diminishing their sense of obligation to provide care themselves.

Lower-income families are less likely to purchase services and express stronger filial obligation.

Marital disruption and remarriage have a major impact on parental support and filial obligation. Divorce disrupts the exchange of support between parents and children. Some research suggests that divorced children feel less filial obligation. Additionally, divorce affects the amount of resources available to help family members and breaks ties that may be

important for the needs of their parents. In addition, divorces and remarriages may increase the number of potential care recipients per adult child by adding stepparents and other step relatives. Having more kin as potential care receivers may diminish the amount of care given by each one. Widowed and divorced parents receive more help than married parents.

Financial factors also play a role. Aging parents with higher financial resources can purchase services and may access services of higher quality, thereby diminishing the need for some types of informal care from children.

Interrelationship between the adult child and the aging parents Affectual solidarity between parents and their children is a major factor in the exchange of intergenerational support. Adult children who witnessed their parents care for their own parents are more likely to provide support, emphasizing the role of social learning on the likelihood of parental caregiving. The presence of siblings in the family is also a predictor of intergenerational assistance.

Only children are relied upon for all necessary support, while individuals with siblings can share responsibilities. Most research in the United States shows that older parents who have more children receive higher levels of support.

The presence of young children in the adult child’s house is a competing demand that diminishes the capacity of adult children, and especially women, to provide support to their aging parents. Greater geographic distance and limited face-to-face contact also reduce the incidence of all types of intergenerational exchanges and represent a significant barrier to intergenerational support.

Effects outside caregive r-care -receiver dyad Most research shows that women’s paid work does not change the likelihood of caregiving. When faced with the need to provide parental caregiving, employed women are likely to withdraw from the labor market, sacrifice leisure activities and sleep, pass up opportunities for promotion, use vacation and sick days for parental care, cut back on some housework activities, and reduce work hours. Recognizing these pressures, caregiving advocacy organizations have called for greater flexibility in the workplace (eg, flex time, remote work, employee assistance programs, adult day programs on site).

The availability of formal services, supported through public sector investment, will affect the need for informal support. Advocates of small government fear that such services will “crowd out” families and lead to less efficient service provision. An alternative view suggests that families and

formal services complement each other in an efficient division of labor. For example, formal organizations are optimal in managing technical tasks in caregiving, while primary groups, such as families, are optimal for managing nontechnical support. As a result, a partnership between formal organizations and primary groups may be the best approach to negotiate informal and formal care.

Traditionally, African-American and Latinx cultures were viewed as giving greater emphasis to family ties (“familism”). However, recent research suggests type of support rather than level of support may best differentiate variation in caregiving.

Stress is a common response to physical, cognitive, and emotional challenges. The stressed person will experience adverse physiologic effects (primarily in the pituitary-adrenal axis and immune system) but also clinically appreciable effects on decision making, problem-solving, vigilance, social inference, and perceptual and motor skills. In this case, stress, a normal feature of interaction with an environment, becomes distress, prolonged stress that overwhelms physiologic and psychological regulatory mechanisms. Prolonged stress may be associated with accelerated aging.

For older adults, the rising prevalence of chronic disease and disability, increased awareness of cognitive or physical limitation, loss of valued social roles, and reduction in social networks through widowhood and loss of friendships all act as stressors that increase the risk of negative mental and physical states. The adverse effects of stress are lower for those who have strong social support systems and greater personal resources, but repeated losses in multiple domains may overwhelm supports.

Yet a robust finding from a variety of research settings has shown that older adults are able to maintain a sense of control even in quite challenging health circumstances. The older woman unable to leave the home or nursing home floor will station herself in a strategic position to retain a view of activity and encourage social interaction. The older man unable to ambulate in his home will place himself in a chair by the window that affords the clearest view of what is happening outside the home. In these ways older people with poor health and threats to autonomy or control may yet retain command over features of their living space.

Stressful life events have been linked to poor mental and physical health in individuals of all ages. Researchers interested in the relationship between stress and health have generally pursued two strategies to assess life event stressors. Major life events such as illness and death of a loved one are often assessed using checklists or interviews to gauge the frequency and intensity of these types of experiences. Daily hassles, on the other hand, are the bothers and challenges of day-to-day living and are measured with structured self-report or interviewer-administered instruments.

Compared to younger persons, older individuals experience fewer life events overall, although they experience more events involving loss, particularly those associated with declining health and deaths of friends and loved ones. Younger individuals report more hassles in the domains of finances, work, home maintenance, personal life, and family and friends, whereas older men and women report more hassles in domains reflecting social issues, home maintenance, and health. Overall, for both younger and older individuals, daily hassles are more potent determinants of physical and psychological well-being than major life stressors.

Older individuals demonstrate remarkable ability to adapt successfully to major life stressors. One important exception to this general observation occurs when older individuals are exposed to unrelenting chronic stressors, such as having to care for a spouse with Alzheimer disease. Under these circumstances the chronicity, intensity, and variety of stressors impinging on the caregiver exact a high price in physical and psychiatric morbidity, including increased risk of substance abuse, and in rare cases murder- suicide.

The considerable variability in response to major life stressors reflects resilience associated with aging. Resilience is the ability to recover from or benefit from adversity. Individuals able to overcome adversity are thought to have high levels of resilience, a combination of internal personality traits such as hardiness, self-efficacy, mastery, and optimism, along with a strong external support system. However, the empirical and clinical utility of the concept of resilience remains to be determined.

Because increasing age is associated with significant alterations in the functioning of many physiologic systems, old age has become a fertile ground

for examining the relation between stress, biological mediators, and disease. For example, a significant body of research views family caregiving as a chronic stressor with the ability to disrupt immune and neuroendocrine function. Compared to noncaregiver older adults, older caregivers have higher antibody titers for latent viruses, poor immune control over latent viral infections, reduced responsiveness of natural killer (NK) cells to cytokine signals, slower healing of wounds, poorer antibody responses to vaccination, and higher levels of basal cortisol. Physical health effects of caregiving include greater risk of infectious disease, hypertensive changes, increased prevalence of cardiovascular disease, and mortality. These findings suggest a strong link between stress, biological mediators, and illness; however, few studies have examined the progression of stress as a biological mediator of disease over time.

Personality is defined as psychological characteristics and attributes and associated behavioral patterns that differentiate one person from another. Personality has long been of interest to researchers, especially with respect to how it develops and may change across the lifespan. The five-factor model (FFM) of personality has been influential among gerontologists and claims that personality can be defined by five broad traits—openness to experience, conscientiousness, extraversion, agreeableness, and neuroticism

—that remain relatively fixed into old age. Other important traits include mastery or control, the belief that important outcomes in life are under one’s own control, as well as optimism and hostility. Despite the relative stability of key traits, functional declines in late life may erode one’s sense of mastery, extraversion, or optimism.

An important emerging area of research is focused on the link between two distinct dispositional attributes and health. Enduring negative effects, such as anger, depression, and anxiety, increase the risk of morbidity and mortality, while positive effects have been linked to lower morbidity, decrease in symptoms and pain, and increased longevity. Multiple mechanisms account for the relation between dispositional affect and morbidity and mortality, including health practices such as diet, exercise, and sleep quality, biological processes such as cardiovascular reactivity, and the effects of the stress hormones epinephrine, norepinephrine, and cortisol.

around, they may also accrue health benefits through more positive social interactions and more attentive and higher-quality health care from health care providers.

Emotional life changes across the lifespan. If one talks to older people and asks about the emotions, one is likely to hear statements about the decline of emotion: “the highs are not so high anymore, but the lows are not so low either.” Older people speak wistfully of their more intense emotional life at younger ages but also report a good deal of relief at getting off that treadmill.

Population surveys, such as the General Social Survey (GSS) and Eurobarometer, track the prevalence of reported effects by age and across birth cohorts and confirm this broad pattern. “Hot emotions,” such as feeling excited about something or feeling overjoyed, decline in age cross-sections. For example, in the GSS the proportion reporting they were overjoyed about something at least 1 day in the last month was 71% in people aged 18 to 29, 56% in people aged 40 to 49, and 47% in people aged 70+. By contrast, the proportion reporting they were fearful about something was 47%, 45%, and 30% in the same age groups. The contrast confounds developmental and birth cohort effects, but such changes have been reported as well for longitudinal cohorts.

The GSS and Eurobarometer surveys (which cover 72 countries and over a half million respondents) show that “life satisfaction” and depressed mood follow a U-shape distribution over the lifespan. Life satisfaction is assessed with subjective global appraisals, such as “Taken all together, how would you say things are these days—Would you say that you are very happy, pretty happy, or not too happy?” Table 4-1 shows the age at which life satisfaction is lowest in cross-sectional surveys, adjusted for a number of important covariates, such as income, health indicators, marital status, and education.

Life satisfaction is lowest at age 40 to 50 in both men and women and remarkably stable across continents.

TABLE 4-1 ¦ AGE AT WHICH LIFE SATISFACTION IS LOWEST

Self-reported depressed mood follows the same pattern. Using the same surveys, depressed mood is also most common at ages 40 to 50, as shown in Figure 4-4.

FIGURE 4-4. Depressed mood over the lifespan. (Adapted with permission from Blanchflower DG, Oswald AJ. Is well-being U-shaped over the life cycle? Soc Sci Med. 2008;66[8]:1733– 1749.)

If we turn to changes at older ages, we find that variation in emotional experience is related less to age than to disability, as shown by results drawn from the Women’s Health and Aging Study, WHAS-I. The sample included

the most disabled third of older women living in the community. The sample of over 1000 women was divided into three age groups (65–74, 75–84, 85+) and three disability groups: women with “moderate disability” (limitations in upper extremity, lower extremity, or instrumental activities of daily living [IADLs] but no difficulty with the basic activities of daily living [ADLs], such as bathing or dressing), those with ADL difficulty who were able to manage without personal assistance, and those with ADL difficulty who received personal assistance.

Table 4-2 shows little variation by age group; mental health and emotional experience were quite similar across the age groups. Table 4-3, by contrast, shows the very strong association between disability and virtually all the indicators. For example, the proportion with depressed mood was 13% in women with moderate limitations, 16% in women with ADL difficulty not receiving help, and 29% in women with ADL difficulty who received personal assistance. The corresponding proportions by age group for depressed mood were 19% (age 65–74), 17% (age 75–84), and 14% (age

TABLE 4-2 ¦ AFFECTIVE EXPERIENCE, WOMEN’S HEALTH AND AGING STUDY I, BY AGE GROUP

TABLE 4-3 ¦ AFFECTIVE EXPERIENCE, WOMEN’S HEALTH AND AGING STUDY I, BY DISABILITY STATUS

Results from WHAS-I show the strong effects of disability and poor health on mood, yet also great resiliency in the face of health limitation. About three-quarters of women with the most severe disability reported satisfaction with help. Over half the sample with the most severe disability still reported they were able to provide assistance to others to a satisfying degree. “Satisfaction with variety in life” declined from 70% to 51% across categories of disability, but again more than half of the women with severe disability reported satisfaction. By contrast, “satisfaction with the meaning and purpose of your life” was stable across age and disability categories; about three-quarters of these women, whatever their age or level of disability, reported such satisfaction.

Finally, this sample of women on the whole reported relatively low self- efficacy. Less than half reported confidence they could accomplish “anything I really set my mind to do.” However, only a minority reported “helplessness,” under 10% in the less severe disability groups and 20% in women receiving assistance with ADL tasks.

This inquiry suggests that disability has only a minor impact on mental health and general well-being. This is an important result. Most of the women in this sample were able to maintain well-being despite disability.

One theory advanced to explain these changes in emotional experience with age and disability involves “socioemotional selectivity.” The theory begins with recognition of the effect of limited time. Aging, health limitation, losses, and disability give time a different significance. Present-oriented goals are given greater value. Thus, older people will be more content with ongoing satisfying social experiences rather than novel experiences that may be emotionally “risky” (because they may be unsatisfying). This awareness

of limited time leads to motivational changes that promote well-being and social adjustment and a skew in attention toward positive information. These theoretic predictions have been confirmed in a variety of experimental settings and may have a neural substrate. An unfortunate consequence may be greater susceptibility to financial scams.

A related theory of psychosocial aging suggests that emotional change is part of a more general “selection, optimization, compensation” process.

Older people become expert in managing depleted resources. Successful aging requires selecting domains to focus limited resources, optimizing investments of time, energy, and emotion to maximize gains, and compensating for losses. Minimizing losses in the emotional domain is consistent with socioemotional selectivity.

Aging in place refers to the ability to remain in one’s home and community even when facing health and challenges in function. Surveys show that the majority of older adults with deteriorating health prefer staying in their home rather than moving to an institutional setting, and research suggests a positive relationship between aging in place and the well-being of older adults. The familiarity of the surroundings and the embedded social network and social support of neighbors may support well-being. Beyond the benefits to older adults and their families, opportunities to age in place also contribute to the community as a whole. Older adults remaining in the community may support others through volunteering or caregiving activities. Furthermore, aging in place is superior to institutional care because of lower costs to families and government-funded long-term care. However, residence in skilled nursing facilities may be cost-effective relative to home care in the case of older adults who require 24-hour care or advanced medical technologies.

Successful aging in place relies on the availability of supportive physical, social, and economic elements within the infrastructure of cities, towns, and communities. Since such elements may benefit other age groups, it is common to refer to communities that make a focused effort to increase safety and accessibility as age-friendly cities or livable communities. A report from the Stanford University Center on Longevity and MetLife Mature

Market Institute provides a summary of the most important elements of a livable community required for successful aging in place. These elements, depicted in Figure 4-5, identify the economic, social, and environmental supports that sustain older adults in their communities, including:

FIGURE 4-5. Aging in place, characteristics of livable communities. (Reproduced with permission from Liveable Community Indicators for Sustainable Aging in Place. March, 2013. MetLife Mature Market Institute.)

The World Health Organization (WHO) has developed a guide for age- friendly cities, which includes similar elements, as depicted in Figure 4-6. Both the MetLife and WHO models recognize that the physical, social, and economic environment is critical, but that successful aging in place also requires adequate individual resources, such as availability of supportive care, either through paid in-home services or from family or other informal caregivers.

FIGURE 4-6. Aging in place: age-friendly domains. (Reproduced with permission from World Health Organization, 2007. Global Age-Friendly Cities: A Guide. Geneva, Switzerland: WHO Press; 2007.)

Long-term care encompasses a wide spectrum of personal care services provided to individuals who need continual support. One end of the spectrum of services is informal care provided at home by a family member, typically a spouse or adult child. On the other end is around-the-clock care provided

by trained clinical teams in a skilled nursing facility. Between the two we find a variety of services that vary in the intensity, location, and cost of care.

The different options available to an older adult at home, in the community, and if needed, in residential settings are shown in Figure 4-7. Options for supportive care in the home include paid in-home health care, provided by nurses and allied health professionals, as well as homemaker and personal assistance services, provided by paraprofessionals. Other in- home services include home-delivered meals, social visiting from neighborhood organizations or programs such as the Senior Corps Companions, and support for medical equipment, such as oxygen, lymphedema support, adjustable beds and chairs, lifts, and respiratory devices. Home modification to address mobility limitation may also be considered an in-home service. Community supports for aging in place include adult day care, congregate meals, senior center programming, and transportation services. These services in the home and the community are designed to help older adults to age in place by addressing their needs as well as the needs of informal family caregivers.

The services range in intensity and frequency. Some provide a solution to a specific problem and thus support older adults who are otherwise independent. For example, home-delivered meals, or “Meals on Wheels,” cover one-third of the daily nutrition needs of older adults. Subsidized transportation services may allow otherwise independent adults to get to and from medical appointments. Other services may provide a more intensive level of services for individuals who need a more comprehensive set of supports, such as home health aides for personal care or adult day programs for people with mild to moderate dementia. Given adequate assessment and care management, individuals with nursing home-equivalent needs can be maintained in their homes. Indeed, care management services provided through Medicaid and Administration on Community Living Title IIID funds often require that these older adults be “nursing facility clinically eligible” (NFCE).

Similarly, residential services offer varying degrees of support based on the continuum of care. These range from independent living residences with occasional nursing or social service support (as in naturally occurring retirement communities, or NORCs), to assistive living communities and personal care homes (residences integrated with health services and communal meals and housing services), to skilled nursing facilities. Some of these residential services offer the full continuum of care whereby residents can move from more independent living settings to more supportive settings as their needs change.

It is important to note variability in the functional trajectory of older adults. This variability is important for targeting services to support aging in place. Older adults often face a health crisis, such as a hip fracture, which will require that they be temporarily placed in a restrictive environment, such as a skilled nursing home or rehabilitative setting. Once they regain functioning, they may go back to a less supportive environment, either in a residential setting or in the community.

Well-planned transitions after such health events, so-called “warm handoffs,” are critical for maintaining older people in the community. Adjustment of medication, reassessment of in-home supports, updating of care management plans, adequate communication between providers, and appropriate clinical follow-up are all required to ensure aging in place. As part of the ongoing rebalancing of Medicaid long-term care funding in the United States, we can expect funding for in-home and community-based

services (HCBS) to grow and greater opportunities for aging in place. Currently, these initiatives are mostly limited to the Medicaid-eligible population. Older adults who do not qualify for Medicaid must rely on long- term care insurance or purchase such services, which is in many cases unaffordable and not always available and appropriate.

A new and growing approach to aging in place is the “Village” model. Developed as grassroots organizations, these villages provide older adults living in the community with a combination of supportive services, such as transportation, housekeeping, and companionship, and a referral service for vetted community services, potentially at a reduced rate using their bargaining power. Villages are similar to the NORC with Supportive Services Program (NORC-SSP), as they provide supportive services to allow for successful aging in place, yet are initiated, governed, and funded (through membership fees) by the consumers they serve rather than by an agency. While each village operates with autonomy as a response to the local needs, the village to village (VtV) network provides help in establishing and managing villages.

A productive way to support psychosocial health among older adults is to harness community-based agencies that provide aging services. These agencies have regular contact with vulnerable elders and are sometimes the only source of such contact. For example, virtually all aging services providers provide social visiting or other “check-in” services, in which agency staff or volunteers call seniors who receive services to stay in contact and unobtrusively determine new needs. These kinds of contact may uncover mental health needs and could be explicitly harnessed for assessment of depressive or anxiety symptoms and, when needed, referral. But the challenges of developing such programs are not trivial. How should staff or volunteers, who often lack mental health training, be trained? What kind of supporting staff needs to be attached to agencies for mental health services?

What kind of referral pipeline would best link aging services providers to mental health services?

A number of such programs have recently been developed and assessed in randomized trials. Many have achieved status as evidence-based programs and have undergone stringent review by the federal Administration for Community Living (ACL). The National Council on Aging (NCOA) maintains a database of evidence-programs. The review process involves assessment of both quality of research and readiness for dissemination for interventions that have already shown effectiveness in randomized-controlled trials or quasi-experimental studies.

Civic engagement is the process by which individuals actively participate in the life of their communities through individual and collective activities. The engagement can range from participating in collective activities such as voting, to participation in religious, spiritual, or community groups, to volunteering time in unpaid productive activities. Older adults commit more hours to volunteering than any other age group, although recent birth cohorts are less likely to volunteer than earlier cohorts. Volunteering contributes to the community and is associated with a variety of personal benefits.

Volunteering is associated with positive outcomes across a number of domains. In the psychosocial domain, volunteering is associated with a reduction in depressive symptoms and improvements in life satisfaction and social support. Volunteering is also associated with better overall health, reduced functional limitations, and lower mortality risk. Experience Corps was a major randomized controlled trial to assess the health effects of volunteering. This program places groups of older adults in public elementary schools to work with children in kindergarten through third grade as tutors and teacher’s aids. Each volunteer serves about 15 hours per week, usually over 3 to 4 days, throughout the school year. Volunteers work with students to promote reading and arithmetic skills, as well as problem-solving and conflict resolution. The program aims to improve children’s academic performance, for example, by boosting school attendance, graduation rates, and performance on standardized tests; but it also aims to improve older adult outcomes by simultaneously enhancing psychosocial, physical, and cognitive well-being. Experience Corps was hypothesized to promote these

outcomes through specific pathways, as shown in Figure 4-8, and demonstrated benefit in a number of domains.

FIGURE 4-8. Causal pathways through which volunteering may support psychosocial, physical, and cognitive functioning. (Reproduced with permission from Fried LP, Carlson MC, Freedman M, et al: A social model for health promotion for an aging population: initial evidence on the Experience Corps model. J Urban Health. 2004;81(1):64–78.)

While less research is available on the effects of volunteering for cognitive functioning, a randomized controlled trial of group volunteering in elementary schools, Experience Corps, showed improvements in cognitive function. While postretirement volunteer activities show positive effects on health and well-being, these activities are also important for generative reasons: While helping those in need, this kind of engagement taps into broader prosocial or altruistic interests, which in itself is satisfying and may offer psychological reward (the so-called “positive glow” associated with helping others). Benefits to older volunteers increased if volunteer opportunities have a prosocial component and if people feel they are appreciated for their contribution.

Another important effort to promote volunteerism among older adults is the Senior Corps program. Senior Corps, funded by the US Corporation for National and Community Service, provides aid to senior citizens while promoting a sense of community. There are about 360,000 volunteers in the

program nationwide each year. Senior Corps focuses on helping individuals aged 55+ to become mentors, coaches, or companions to people in need, and in this way contribute their job skills and expertise to the community. Senior Corps has three flagship programs, including (1) Senior Companions, in which volunteers provide assistance and friendship to adults who have difficulty with daily living tasks, as well as support to family caregivers by providing respite; (2) RSVP, which connects interested seniors to service opportunities, such as organizing neighborhood watch programs, tutoring or mentoring disadvantaged children, and teaching English to immigrants; and

(3) Foster Grandparents, in which older volunteers tutor children, serve as mentors to at-risk teenagers and young mothers, help with care for premature infants and children with disabilities, and work with abused or neglected children.

Much like volunteer activity, continued learning in old age has been associated with positive effects in psychosocial, physical, and cognitive health. One of the leading organizations in this area is Road Scholar educational adventures, formerly known as Elderhostel, a not-for-profit world organization facilitating lifelong learning in various locations in the United States and internationally. Some of these learning opportunities allow for a grandparent-grandchild combined learning experience, thus including an intergenerational component.

Another important model is the Osher Lifelong Learning Institutes (OLLI). The Osher Foundation supports lifelong-learning programs on US university and college campuses, with one or more programs in each of the 50 states and the District of Columbia. The Foundation also supports a National Resource Center to enhance programming and outreach. These efforts involve a membership-based community of adults, “age 50 and better,” who take classes on campus, both traditional classes with undergraduates but also classes taught by members, who, in many cases, are retired academics and teachers.

Older adults face many life transitions or changes in roles related to age and declining health. A key age-related transition is retirement. Major health- related transitions include bereavement due to loss of a spouse or partner and

the onset of caregiving when a spouse or partner experiences declines in health.

The loss of employment represents a meaningful life event for older adults, and in the early literature was described as a transition to a “roleless role” that clashes with the emphasis on productivity and a busy work ethic and thus must lead to negative effects. Yet empirical studies did not find uniformly negative effects of retirement. While some research showed that retirees were more likely to report depressive symptoms, loneliness, lower life satisfaction, and reduced activity, other research showed that older adults are satisfied following retirement. Using longitudinal data from two nationally representative samples from the Health and Retirement Study, researchers demonstrated that there were multiple paths following retirement over time.

About two-thirds of people experienced minimum changes in psychological well-being, about a quarter of individuals showed initial negative well-being effects followed by improvement, and a small group of people showed immediate positive changes.

Current retirement trends suggest that older people are now maintaining full employment to later ages (in 2019, about 17% of men aged 70+ and 10% of women aged 70+ were employed). More importantly, retirement is no longer an abrupt transition from a full-time career to no employment. Instead, current retirement behavior suggests that many older adults remain in work in later years, choose partial retirement through reducing work hours, take bridge jobs if their long-term career ends, or even start their own businesses. It is also clear that volition and choice are important in adjustment to retirement, with those choosing to retire reporting greater satisfaction than those who felt obligated to retire. Good health and adequate income are also important determinants of postretirement adjustment.

The transition to widowhood is among the most stressful transitions in later life. The well-being of the surviving spouse depends on features of the end- of-life period. Strains associated with bereavement are ameliorated if physical discomfort is kept to a minimum and families provide support.

Research suggests that men and women who report greater independence are better able to adjust to loss of a spouse or partner. This may suggest that

Widowhood is a transition that leads to the reconfiguration of family roles and functions. While less likely than their married counterparts to have a confidant, widowed individuals are more likely to receive support from children, friends, and relatives. Widows are also more likely than their married counterparts to pursue volunteer roles, which in turn can lead to improved health and well-being.

When older adults require caregiving, the spouse is the first line of defense. Spousal caregivers seem to exhibit levels of depressive symptoms similar to adult children who are caregivers yet derive less emotional rewards from caregiving. Wife caregivers tend to suffer greater adverse effects than husband caregivers (especially when caregiving duties restrict outside activities); they also experience greater caregiver burden and depression than husbands. Caregiver adjustment is also affected by marital quality prior to assuming caregiving duties. In marriages with higher levels of marital disagreement pre-caregiving, spousal caregivers report a greater decline in happiness and a greater increase in depression during the caregiving period than spouses in more cordial marriages. A caregiver’s well-being is sensitive to the condition of the spousal care recipient, with those caring for spouses with dementia experiencing higher levels of negative effects on well-being.

Older adults are the first of line of recourse for caregiving support when the parental generation is unavailable due to incarceration, disease, substance abuse, or other conditions. Caregiving grandparents typically face challenges beyond their role as caregivers. They tend to live in poverty and rely on public assistance, are less educated, and in many cases do not have access to adequate health care.

The demands of caring for grandchildren have negative effects on the well-being of custodial grandparents. Cultural expectations for care arrangements in this case also have mental health consequences. For example, a cross-cultural comparison found that African-American grandmothers who were sole providers for their grandchildren were less

distressed than comparable White grandmothers. In cultures that rely on extended families, caregiving stresses associated with grandparent care for grandchildren may have less negative effects.

Cognitive, physical, and sensory limitations in older adults often limit informed decision making in medical encounters. Yet older adults continue to show interest in making informed health care choices, and patient-centered care will require innovations that promote engagement of older adults in care decisions. It is valuable to ask if older adults feel they are adequately informed about their health care choices and to identify the psychosocial correlates of “informed care.”

In one large cohort of very old adults (mean age 86), participants were considered “informed” about their healthcare choices if they reported that (1) a health care professional checked to see that they understood their condition and care, and (2) the health care professional gave them enough or more than enough information about their medical condition. Participants reported on their most recent medical encounter. By this standard, three-quarters of participants met criteria for informed care. Participants who met criteria for informed care were less likely to report depressed mood.

Quality of life (QOL) includes two overlapping domains. Health-related quality of life specifies elements of daily function and well-being that change as a result of disease or therapeutic intervention. A satisfactory QOL measure in this sense allows researchers to rank different health conditions (and treatments) according to their impact on domains of health, such as mobility, independence in bathing and dressing, sensory acuity, mood, and absence of pain. The more negative the impact in these areas, the greater the quality of life impact of the health condition. Environment-based quality of life, by contrast, is not a health impact measure but rather registers the effect of personal resources or environmental factors on daily experience.

Environment-related QOL domains include features of the natural and built environment (such as economic resources, housing, air and water quality,

community stability, access to the arts and entertainment), as well as personal resources (such as the capacity to form friendships, appreciate nature, or find satisfaction in spiritual or religious life).

Health-related QOL can be assessed as the difference between a population norm and mean value for patient samples, or more directly as a “utility” rating, that is, a numeric rating of how preferred (and thus how much better) one health state is relative to another. One common way to derive utilities for health states is to ask how many years of life people would be willing to give up to live without a health condition or disability.

The psychological analog to quality of life is valuation of life (VOL), the extent to which the person is attached to his or her present life. VOL can be measured by reports of hope, the sense that life has meaning, and continued commitment to personal projects, that is, goal-driven activity. VOL is independent of many factors associated with health-related QOL, such as health state, cognitive capacity, and mental health. VOL was a significant independent correlate of the wish to live under a great range of severe health limitations, including states of mobility impairment and severe pain.

However it is measured, health-related QOL declines with age. This is a central, inescapable consequence of the increased prevalence of chronic disease with greater age and the effects of senescent changes in many physiologic domains. As we have seen, older people adjust their daily lives to accommodate these decrements, and adjustment strategies may reduce the effects of such decrements on health-related QOL. Still, cross-sectional studies show strong declines in health-related QOL with increasing age. VOL may not show so clear a pattern. Here we need to ask when the wish to hasten dying is an expression of discouragement based on depression, and when it is an expression of discouragement based on a judgment that life no longer has intrinsic value because impaired health does not allow meaning, purpose, or desired personal projects.

In contrast to health-related QOL, environment-related QOL may remain high throughout life and may even improve with greater age. With retirement, for example, older people have greater leisure time; and with children gone, houses paid for, and successful investments, they may have greater disposable income as well. As a result, older people have increased opportunities to develop interests and create satisfying environments. These freedoms and opportunities counterbalance declines in health-related QOL

and may be responsible for the great resiliency older people show in the face of declining health.

Dying in America has changed markedly in the past quarter century and continues to evolve as the population ages, treatment of chronic disease becomes more effective, and clinicians, policymakers, and the public refine practices related to end-of-life care. “Dying” can be considered a new, emerging stage of the life course: Unlike dying in the past, dying now can be protracted (as with cancer), planned, involve new awareness and self- definition, and require particular developmental psychosocial tasks and challenges. Older adults with life-limiting illness and their caregivers face an increasing array of treatment choices at the end of life as well as an expansion in settings for receiving care, including hospice (which mostly involves in-home services). Half of the deaths in the United States involve hospice care, with the predominant arrangement involving hospice services delivered in homes. However, this care is usually implemented only a few days before death, preventing patients and families from receiving the full benefit of hospice. In 2015, 1.6 million people received hospice care in the United States, and 33% were age 85 and older.

As hospice becomes the predominant model for end-of-life care, it is important to monitor its psychosocial costs and benefits. Use of hospice services is associated with greater satisfaction with quality of dying, better quality of care at the end of life, and less conflict in decisions regarding care and treatment. On the other hand, use of hospice also involves greater investment of time and effort on the part of family members, as evidenced by the higher proportion of caregivers who administer medications and report taking time off from work during end-of-life care compared to caregivers who do not make use of hospice. Despite this greater involvement in end-of- life care, caregivers who make use of hospice do not report a greater prevalence of depressed mood, anxiety, or postdeath persistent grief, suggesting that involvement in hospice buffers the negative impact of greater involvement in end-of-life care.

Aggressive treatment at the end of life remains common among older adults. An analysis of nearly 30,000 Surveillance, Epidemiology, and End Results (SEER) patients aged 65+ (all with a cancer diagnosis), for example, showed an increase in aggressive cancer care near the end of life, as

indicated by the proportion starting a new chemotherapy regimen within 30 or 14 days of death; the proportion with more than one emergency department visit, more than 14 days in hospital, or an intensive care unit (ICU) admission in the last month of life; or the proportion of hospice patients with length of stay fewer than 3 days. Nearly 20% continued to receive chemotherapy in the last 2 weeks of life. More generally, analyses of Medicare claims show a decline in the likelihood of dying in an acute care hospital but a high prevalence of 30% for use of the ICU during the last month of life.

Aggressive interventions before death are declining in people with advanced dementia, as shown by decreases in rates of hospitalization, emergency room admission, and feeding tube placement in the last 3 months of life among residents of skilled care facilities. For some therapies with no clear benefit for this population, such as parenteral feeding tube placement, clinicians have recommended that this choice no longer appears as an option in advance care planning documents, such as the Physician Orders for Life- Sustaining Therapies (POLST). The difficulty of preparing for end-of-life treatment is visible as well in recent discussions on the best way to deprescribe medications that are no longer appropriate.

Defining advance care planning is challenging. A consensus statement did not emerge until 2017: “Advance care planning is a process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care.

The goal of advance care planning is to help ensure that people receive medical care that is consistent with their values, goals and preferences during serious and chronic illness.” In partnership with health care professionals, families face the challenge of limiting inappropriate care for older adults who are dying or who are unlikely to benefit from aggressive hospital interventions because of frailty or multimorbidity. The high risk of death in late ages (8%–10% per year in people age 85+ and over 30% per year for people aged 90+) suggests that clarifying preferences for end-of-life treatment should be a priority for the very old. Yet “the talk,” discussion of end-of-life treatment preferences among older people and their families, is often difficult. Older people are more likely to initiate such discussions than their adult children. Adult children may resist such discussions and are often more in favor of aggressive treatment at the end of life than parents. Older adults completing POLST are less likely to receive aggressive treatment at

the end of life in nursing homes but not in admissions through the emergency room.

Deaths are challenging for survivors as well. Estimates suggest that 9% to 25% of older people are unable to recover from the emotional challenges of the death of a loved one and develop persistent or complicated grief.

DSM-V has defined this complex bereavement disorder as a trauma or stress- related condition lasting 6 or 12 months after the death. In older adults, complicated grief is associated with disability, cognitive impairment, and suicidal thinking. New measures are available now to assess persistent grief, such as the Inventory of Complicated Grief, and a number of trials have shown that psychotherapy targeted to complicated grief is more effective than standard grief-focused interpersonal psychotherapy.

A final consideration is distress and regret at the end of life, which may be impairing even if not accompanied by frank depression or anxiety. Such distress often reflects active questioning of the meaning of life, such as whether a person has made good use of a life and left an appropriate legacy. Since patients with a higher sense of meaning experience less distress at the end of life, interventions that bolster meaning may reduce this existential distress and accordingly lower the risk of poor mental health at the end of life. One promising approach to supporting meaning at the end of life is dignity therapy, a short-term psychotherapy that has been shown to improve well-being in people with life-limiting illnesses. In dignity therapy, patients complete a guided elicitation of the major accomplishments of their life, which, after editing and revision, is shown to family and placed in the medical chart as a statement of the value of the life lived.

Assessment of psychosocial domains is an integral component of the comprehensive geriatric assessment (CGA) in an older adult. Geriatric syndromes such as malnutrition may be multifactorial in origin, including psychosocial causes like substance abuse, social isolation, and psychiatric disturbances.

A detailed psychosocial history is very important in the evaluation of any geriatric patient. The CGA in older adults includes ascertainment of social support, depressive symptoms, mood, financial concerns, whether one has

durable power of attorney for health care, religious and spiritual beliefs, availability of caregivers to support ADLs, home safety, and caregiver burden. It can give information on a need to change the living situation or to consider placement.

Patient-centered goal setting is very important in the management of any patient and this is particularly so in an older adult patient. He or she may prefer quality of life or the ability to attend a major family event over even survival.

Psychosocial factors are critical contributors to the health and quality of life of older individuals. We have focused on factors that appear to be most potent for explaining variability in health outcomes using a broad conceptual model that shows how psychosocial factors contribute to behaviors and biological processes linked to illness and quality of life. These effects do not occur in a vacuum but rather are set within the larger social and cultural contexts in which people live. The life course perspective shows how the experience of aging depends on cultural factors, such as the conceptualization of the lifespan, as well as biologically driven developmental changes in social and affective experience. A significant advance of the last decades is research showing how psychosocial factors get “under the skin” to affect the physiology and functioning of the organism, and hence health and quality of life. Continued advances in mind-body science along these lines will

enhance our understanding of the relationships between biology, psychology, and social experience and will provide new opportunities for intervention.

A second theme of this chapter is the remarkable resilience of older individuals. Despite significant declines in multiple functional domains in late life, most older individuals adapt well to the challenges they face and maintain high quality of life. Depression and dissatisfaction with life do not come in late life, but earlier, in mid-life. While psychosocial health is clearly affected by disability, it is remarkable that majorities of older people with substantial disability report high levels of positive affect and involvement in daily life. This resilience reflects finely tuned adaptive mechanisms that maximize the ability to cope with major life challenges. Common old-age transitions such as retirement, widowhood, health decline, and caregiving, are challenging; but older people are able to navigate these changes through selection, optimization, and compensation to maximize function and well-

being. Consistent with the greater socioemotional selectivity of old age, the landscape of affective and social experience changes and may look narrow to younger people; but the greater reports of satisfaction and happiness typical of old age suggest that these processes help buffer more challenging features of aging.

Finally, a third theme is the strong association between social engagement and well-being. Lack of support (social isolation and loneliness) has a negative effect, and social engagement (volunteering, lifelong learning, and involvement in intergenerational programs) has a positive effect. Beyond these social factors, many kinds of intervention support psychological health. For example, the aging services network is important in promoting engagement across diverse domains, with clear benefit. Social environments that promote aging in place, involvement of older adults in their care and in health decision making, and supporting family caregivers who provide end- of-life care all offer benefits and show it is possible to promote engagement across multiple levels and domains. New models of engagement, such as school-based volunteering and intergenerational programs, suggest that engaging older adults may be good for older adults as well as other age groups. This kind of programming will likely become more important as increasingly larger cohorts of older people reach old age in better health.

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Sweden has the longest period of reliable birth and death records of any country. Beginning in 1751 these records are moderately reliable, and they are very reliable from 1860 to the present day. Sweden’s life expectancy over this 250+-year period dipped as low as 18 years during periods of famine or pestilence and has risen as high as today’s 83 years. However, in each and every year, regardless of overall life expectancy, women have outlived men (Figure 5-1). The same is true for each of the 41 countries in the Human Mortality Database for every year on record!

FIGURE 5-1. Demographic data from Sweden from 1751 to the present. A. Male and female life expectancies at birth show a steady increase after 1800 with occasional brief decreases due to war, famine, or infectious disease. B. Sex difference (female minus male) in life expectancy at birth and at age 50 is always positive, indicating greater female survival in all years for both ages. (Reproduced with permission from Human Demographic Database.)

To interpret sex differences in longevity—call it the “life expectancy gender gap”—it is useful to understand the meaning of two demographic parameters. The first of these is life expectancy itself. Life expectancy, unlike its name suggests, does not measure the expectation of future life, which is by its nature not really knowable. Life expectancy, as typically used in describing human longevity, measures past life. That is, as most commonly reported, life expectancy is equivalent to the average age of death of all individuals who died during a specific period—usually 1 year. So life expectancy in the United States in 2017—76 years for men, 81 years for women—is equivalent to the average age of all people who died during 2017. More technically, such a measure is called the period life expectancy at birth because it is the average of deaths at any age from birth during a defined period. Unless otherwise specified, life expectancies reported in this chapter (as they are in the literature generally) will be period life expectancies at birth. Life expectancy can be calculated for any other age as well. Life expectancy at age 50, for instance, is the average age of death of those who survived for at least 50 years. Such a measure is useful for eliminating the impact of infant mortality or other early-life events such as military combat, therefore providing better comparisons on the health of older populations. Life expectancy from age 50, as at birth, uniformly favors women not only in Sweden (Figure 5-1B) but in all other countries and at all times recorded in the Human Mortality Database.

Prior to the middle of the twentieth century, most deaths worldwide occurred in infancy. Consequently life expectancy at birth was not particularly informative about the health of the older population. For example, in 1773, the year in which Swedish life expectancy at birth fell dramatically to 18 years (Figure 5-1A), about half of all deaths occurred before age 5. Most adults died in their 40s and 50s, however. Thus the 18- year life expectancy at birth would be highly misleading if used as an indicator of typical ages of adult deaths. Life expectancy at age 50 is considerably more informative about survival of older adults and shows that in the same year, there was a relatively small life expectancy difference (1 year) between men and women. However, as infant and early-life mortality in developed countries has plummeted in recent decades (only 5% or fewer of deaths now occur before age 50 in most industrialized countries), life expectancy—even life expectancy at birth—has become an increasingly useful measure of health in old age because virtually all deaths occur in older adult age groups.

Note that these “period” life expectancies combine deaths from people who were born at different times. That is, a 50-year-old who died in 2010 would have lived through a considerably different health environment than a 90-year-old who died in the same year. For instance, antibiotics and vaccinations against a number of common infectious diseases did not become widely available until the latter half of the twentieth century, so people born earlier in the century survived threats to health not faced by later generations. Sometimes it is useful to compare survival of people who were born during the same period—thus lived in similar health environments from birth— rather than who died during the same period. Life expectancy of people born during the same period is called cohort life expectancy. Cohort life expectancy can be dramatically different from period life expectancy because it records deaths that occur after—often many decades after—rather than

during the eponymous year. Compared to the 18-year period life expectancy in Sweden in 1773, cohort life expectancy was 39 years for women, 36 years for men, and at age 50 it was 21 years for women, 19 years for men. A disadvantage of cohort life expectancy is that it can only be calculated precisely when all the people born at a certain time have died. Therefore, it can only tell us about the relatively distant past. Cohort life expectancies can also fluctuate wildly with events like wars or epidemics where people of a certain age are particularly prone to die. French men from the 1895 birth cohort, for instance, had a 16-year life expectancy disadvantage compared to women, due to the massive war casualties among 19- to 24-year-old men during World War I. Regardless of how it is calculated, life expectancy of women always exceeds that of men wherever records are reliable. The gender gap in life expectancy may be one of the most robust features of human biology known.

The accumulated effects of women’s lifelong survival advantage means that with advancing age there is a progressive excess of women compared to men. Again, using Sweden with its precise, historical birth and death records as an example, there are currently 105 women born per 100 men. By age 80, there are roughly 150 women per 100 surviving men, by age 90 there are 200 women per 100 men, and by age 100 there are nearly 350 women per 100 men. The Gerontology Research Group (https://gerontology.wikia.org/wiki/Oldest_Validated_supercentenarians_All

-Time) is a global e-group of researchers in gerontology that tracks and seeks to validate reports of supercentenarians (age 110 or older). According to their records, about 95% of supercentenarians are women.

Life expectancy differences are the product of survival differences over the life course. A reasonable question is whether women survive better than men at all ages or whether their survival advantage is confined to certain periods of life. Using the United States as an example, during a period in which the gender gap in life expectancy was particularly small (the year 1900 when the gap was 2.6 years), and a period during which it was larger (the year 2000 when it was 5.4 years), several patterns appear (Figure 5-2). First, age- specific mortality, the probability of dying in a specific year, drops sharply from birth to age 10 for both sexes during both historical periods, then climbs at varying rates thereafter. Second, from age 35 on, that climb is log-linear,

the so-called Gompertz mortality pattern—a pattern of aging in which mortality accelerates at a constant rate. From age 50, mortality rate doubling, which is determined by the slope of the line, is virtually the same—about 8 years—in the year 2000 as it was in 1900. It is just that mortality declined by a nearly equivalent amount at all ages. Finally, although survival was markedly improved at all ages, the largest gains over this 100-year time span were those prior to age 50. Women clearly gained significantly more than men.

FIGURE 5-2. A. Age-specific mortality in men and women in the United States in the years 1900 and 2000. Note the logarithmic scale for mortality. In 1900, life expectancy at birth in the United States was 46 years for men and 49 years for women; in 2000, the analogous numbers were 74 years for men and 79 years for women. B. Ratio of male-to-female age-specific mortality. The reference line at 1 marks where male and female mortality is equivalent. (Reproduced with permission from US Social Security Administration, 2005.)

The logarithmic scale of Figure 5-2A makes it difficult to distinguish sex differences in mortality pattern particularly in 1900 where the differences were small, so the ratio of male-to-female mortality is shown in Figure 5- 2B. This analysis shows that in 1900 when overall mortality was high, women survived better during the first years of life, there was little sex difference during childhood, adolescence, and the early reproductive years, then women gained a small but consistent survival advantage throughout the rest of life. Similar patterns are seen in 1900 Sweden and 1947 Japan which also had life expectancies of around 50 years, although in both these cases female mortality slightly exceeded male mortality through the teenage years. It is apparent that as mortality fell and life expectancy increased throughout the twentieth century, women benefited more than men. In particular, men died at much higher rates than women at all ages from age 20 onward. The huge peak in mortality difference shown in Figure 5-2B through the 20s and 30s is as a result of excess male deaths from accidents, homicides, and suicides. This pattern is seen in many, but not all countries. In current Japan, for instance, although male mortality is roughly double that of females through their 20s and 30s, the largest mortality differences are at ages 60 to 80.

Special attention should be paid to lower female than male mortality in the first years of life. A gender gap favoring females in survival from birth to 1 year appears to be as universal as greater female life expectancy, being found in every year of every country in the Human Mortality Database. Given that female babies less than 1 year are unlikely to receive better care than male babies, particularly in the distant past, this survival difference likely reflects an important biological difference between the sexes. The gender gap in survival even extends to prematurely born infants. Neonatologists consistently report that response to therapy and survival among prematurely born infants also favors female over male babies. Thus females appear better designed for survival than males perinatally and even prenatally.

A similar pattern of increasing mortality differences between the sexes over the course of the twentieth century has also been observed in analyses of cohort mortality. An examination of birth cohorts from 1800 to 1935 across 13 developed countries found that the gender gap in adult (ages 40– 90) mortality rates widened dramatically among those born in the late nineteenth and early twentieth centuries (thus typically dying in the latter half of the twentieth century). This widening gap—termed excess male mortality

by the authors—was particularly noticeable at ages 50 to 70 years. The causes for these changes are examined below.

There is considerable variability in the magnitude of the sex difference in life expectancy across time and countries. It may be difficult to avoid biological explanations for the seemingly universal advantage that women have over men in terms of life expectancy. However, the magnitude of the gender difference above a certain irreducible biological minimum is likely to be affected by cultural, environmental, and behavioral factors. Investigation into this variation might provide insight into how some of these factors affect health. For instance, in Sweden between 1750 and about 1950, variability in the gender gap is considerably more pronounced in life expectancy at birth than at age 50 (see Figure 5-1B), indicating that the magnitude of the gap was largely driven by sex differences in survival in early and midlife. However, since the middle of the twentieth century when early-life deaths became a much smaller contributor to life expectancy calculations, the gap has changed in parallel fashion whether measured from birth or from age 50. During this time a striking pattern has emerged. Between 1950 and about 1980, the gender gap rose from near its lowest magnitude to its highest sustained level, then plummeted at its most rapid historical level to its current 3.5-year difference. Such a clear pattern demands explanation.

First, though, it should be pointed out that Figure 5-1B is misleading in one sense. It depicts the gender gap as absolute difference in number of years. Between 1750 and 1950, the period during which the differences appear consistently lower than they became later on, Swedish life expectancy climbed from about 40 years to more than 70 years. An absolute difference of 3 years in life expectancy is arguably more meaningful if overall life expectancy is 40 years rather than 70 years. If the difference is expressed as a percentage of male life expectancy (Figure 5-3A), a somewhat different picture emerges. The gender gap was actually larger for the most part prior

FIGURE 5-3. Gender gap in life expectancy. A. Sweden since 1751 expressed in absolute difference versus as a percentage of male life expectancy. B. Absolute differences in three countries. Note that when Japan’s difference was little more than 3 years (early 1950s), overall life expectancy in Japan was still low by modern standards (60–63 years).

Before discussing possible reasons for this pattern, it might be revealing to look at patterns in several other representative countries (Figure 5-3B).

For some time countries of the former Soviet Union have had the world’s largest gender gap in life expectancy. In Russia that difference now approaches 12 years. This large difference is not due to exceptionally long- lived women, but to exceptionally short-lived men. Russian women are in fact among the shortest-lived women in the industrialized world—their current life expectancy of 77 years is only marginally higher than it was in the 1960s. But health and longevity of Russian men is abysmal. Their life expectancy of 65 years is a consequence of poor diet, poor sanitation, a virtual absence of preventative medical care, and dreadful health habits. As a result, 25% of Russian men die by age 55 compared with less than 10% of women. To place this statistic in an international perspective, only 5% of Swedish or Japanese men die by age 55. The main factors driving the Russian gender gap in life expectancy are smoking and alcoholism. Russian men have traditionally had among the highest smoking prevalence in the world. Fluctuations in the life expectancy gap has also marched in lock step with the availability of vodka. Specifically, in 1985 vodka production was drastically cut and vodka was not allowed to be sold before lunch-time. The gender gap abruptly shrunk as men began living longer. When alcohol availability was later liberalized, the gap expanded again just as abruptly.

Since 2006 when new restrictions were implemented, the gap has again begun to shrink.

Has there been a consistent pattern of change in the gender gap as overall life expectancy has rocketed upward in most industrialized countries in recent decades? Again using Sweden as an example, the life expectancy gap both at birth and at age 50 rose dramatically after World War II, but has fallen steadily since the 1980s (see Figure 5-1B). This is the most common pattern among high-income countries. Similar patterns of rapid increase in the gender gap after World War II, followed by a rapid decrease beginning in the 1980s or 1990s and continuing to the present have been seen in the United States, Canada, Australia, Iceland, and most European countries. The life expectancy gender gap is not declining everywhere, however. In Japan, where life expectancy at birth has grown explosively—nearly 5 years per decade—since the end of World War II, the sex difference also steadily increased until the 2000s where it appears to have stabilized at about 7.5 years (see Figure 5-3B).

The major reason for these various patterns—at least after World War II when causes of death were more reliably recorded—appears to be largely the delayed impact of historical smoking habits. In the United States and most of Europe women’s deaths from lung cancer and respiratory diseases have declined slowly if at all, compared to a relatively rapid decline among men. Smoking of course adversely affects multiple aspects of health in addition to its effects on the lungs, but lung cancer and respiratory diseases serve as convenient indicators of smoking’s impact on general health. As noted previously, women in most western countries took up smoking in large numbers more recently than men and have been slower to stop. In Sweden, smoking is now more prevalent among women than men. An example of the delayed effect of smoking can be seen in data from the United States (Figure 5-4). As with smoking itself, deaths due to respiratory diseases and lung

women somewhat later and have so far declined more slowly than among men. In Japan where the gender gap in life expectancy has not closed appreciably, smoking prevalence among women has always been—and continues to be—very low compared with men. Importantly, both history and biology suggest that despite the recent contraction of the gender gap in life expectancy across most high-income countries, there is likely to be an irreducible floor to the gap of probably about 3 to 4 years.

FIGURE 5-4. Historical changes in smoking prevalence and mortality rate from lung and bronchial cancer in the United States. Note that smoking among women reached its peak later and declined more slowly than among men and lung cancer death rates followed suit with a delay of several decades. (Reproduced with permission from United States Centers for Disease Control and Prevention and National Cancer Institute SEER Database.)

The gender gap is now playing a role in the US declining rank in life expectancy among countries internationally: from 12th in the world in 1950, sexes combined, to 39th for women and 40th for men in 2010—near the bottom of all industrialized countries. The US National Research Council investigated the reasons for this pattern and concluded that American women began smoking in large numbers earlier and more intensively than women in Europe and Japan. Damage from smoking was estimated to account for nearly four-fifths of the sluggish improvement in US women’s life expectancy relative to Europe and Japan. As US women also began reducing smoking earlier than women in many other high-income countries, it is expected that their life expectancy rank may begin to rise over the next several decades.

Does the universal difference in life expectancy between men and women suggest that men age more rapidly than women? This is not an easy question to answer as it requires defining aging—a task that defies simplicity.

One definition often favored by demographers is that aging in a population can be measured by the rate of increase in age-specific mortality. By this definition, men and women age at surprisingly similar rates (see Figure 5- 2A). Note in the figure that in the United States whether one considers data from 1900 when life expectancy was 46 years and 49 years for men and women, respectively, or data from 2000 when life expectancy reached 74 years for men and 79 years for women, age-specific mortality increases from age 40 in almost perfectly parallel fashion in the two sexes. Women simply die at lower rates throughout later life. The same general pattern is seen in almost all countries with reliable death statistics. So at least by this metric, women do not age more slowly than men. They are simply better designed for survival regardless of age.

Another way to define relative aging rates might be to compare the ages at which they get major diseases of later life. Do women tend to die of the same diseases as men, they just get them later? If so, then plausibly women age more slowly than men. Alternatively, maybe women are more resistant than men to only one or a few major causes of death such as cardiovascular diseases and stroke; except for that difference, perhaps they would age at the same rate as men. This latter hypothesis seems unlikely given that the major causes of death have changed historically, while women have always lived longer. It is also not supported by available evidence. Men die at higher rates than women from a broad swathe of diseases with one particularly interesting exception (Table 5-1).

TABLE 5-1 ¦ SEX DIFFERENCES IN TOP CAUSES OF DEATHS IN THE UNITED STATES OVER THE 50-YEAR PERIOD BETWEEN 1960 AND 2017

Comparing causes of death between the sexes and even within a sex over time requires some careful thinking. One common metric of comparison is the simple percentage of deaths caused by a disease. Using this metric, some causes of death have decreased over the past 50 years (eg, heart disease, stroke) while others have increased (eg, cancer, diabetes). This metric can be seriously misleading though. For instance, in 2017 roughly 24% of all men’s deaths in the United States were due to heart diseases, whereas for

women the analogous figure was about 22%. Thus, at first glance heart disease seems to be roughly an equivalent health problem for men and women. Similarly, cancer causes a higher percentage of deaths today (23%) than it did 57 years ago (16%). Does this mean that we are getting progressively worse at preventing and treating cancer?

Obviously not. The occurrence of heart disease or cancer, like 9 of the 10 top causes of death (excluding only cause #10—suicide) in the United States today, accelerates with age. Today, we live roughly 9 years longer than we did in 1960, sexes combined. Thus, we are more frequently succumbing to cancer today compared with 50 years ago simply because we are not dying of other things first. We are also less frequently succumbing to heart diseases despite not dying of other things first and despite living longer. This is truly one of the signature accomplishments of modern medicine.

A critical limitation of using percent of deaths caused by specific diseases is that it masks information on the ages at which death occurs. Presumably, heart disease or cancer should be considered a more serious health problem if it kills earlier in life rather than later. In addition, delaying the onset or progression of these diseases should be considered a sign of medical progress. There is a meaningful health difference in other words between dying of a heart attack at age 50 versus age 80.

The confounding impact of age in the interpretation of health trends can be removed by using age-adjusted mortality rate. This metric gives the relative probability of dying from a disease while controlling for age. If the percent of deaths caused by a particular disease is similar, but the age- adjusted rate is lower for women than men, it indicates that women are contracting the disease later in life or are surviving longer with the disease. For instance, there is currently minimal difference between sexes in percent of deaths due to heart disease (24% for men, 22% for women), but a major difference in the age-adjusted rate (209 vs 130 per 100,000 for men vs women, respectively), indicating that women typically have heart diseases later in life or are better at surviving them. The former appears to be true.

For example, US women have their first heart attack 8 years later than men on average, but are in fact less likely to survive (probably because they are 8 years older when it occurs).

Sex-specific profiles of deaths can be compared as they were reported over a 57-year interval using the 1960 and 2017 US Vital Statistics Reports (see Table 5-1). Because the age-adjustment for 1960 was calculated based

on a different standard population than in 2017, comparison of age-adjusted rates between years is not meaningful. Age-adjustment in this case is useful for making comparisons within years. However, the ratio of male-to-female age-adjusted rates does allow comparison of gender bias in death rates across years.

9.5 years for men, but only 7.8 years for women. Also note the dramatic reduction in percent deaths due to heart diseases, stroke, and respiratory infections. As might be expected with the much older population in 2017, percentage of total deaths from a range of diseases of aging such as cancers, chronic lower respiratory disease, diabetes, chronic kidney disease, and especially Alzheimer disease (AD) increased fairly dramatically as well.

In 1960, males died at higher age-adjusted rates for 8 of the top 10 causes of death. Males died at 80% higher rates from heart diseases and 60% higher rates from influenza and pneumonia. Not shown in the table for 1960 are accidents, cirrhosis of the liver, and tuberculosis, all of which were

male-biased as well (male/female age-adjusted ratios: 1.3, 2.1, and 2.8, respectively). The comparative female resistance to dying of infectious diseases such as pneumonia, influenza, and tuberculosis is not specific to the United States. In Japan in 1960, men died of tuberculosis at twice the age- adjusted rate of women. Such resistance in fact may help explain the historical female survival advantage. In 1900 and presumably earlier, pneumonia/influenza was the leading cause of death, followed closely by tuberculosis. Not shown for 2017 are deaths from accidents, cause #5 (age- adjusted sex ratio: 2.0), and cause #10, suicides (age-adjusted sex ratio: 1.4). By 2017, 9 of the 10 top causes of death were male-biased, although only slightly so for stroke. Thus across a span of 50 years despite better overall improvement in health and survival among men than women, men still died at higher age-adjusted rates from virtually all of the top causes of death.

Note that the same pattern holds true for COVID-19. When the data are in from 2020 and 2021, COVID-19 will rank among the top causes of death. In fact from mid-November 2020 to the current time (February 2021), COVID- 19 killed roughly twice as many Americans as either of the previous top two causes of death, heart disease and cancer. As with influenza and pneumonia, men died at higher rates than women from this emerging disease.

The trend for men to die at greater age-adjusted rates from a diversity of causes is by no means unique to the United States. Among the 28 countries of

the European Union, in which life expectancy ranges from 74 years (Latvia, Lithuania) to 83 years (Iceland), men die at higher age-adjusted rates than women of nearly every top cause of death as well. The same is true in Japan, the country with the highest life expectancy in the world.

In sum, as women do seem to contract multiple diseases of aging (fatal diseases anyway) later in life than men, it is at least arguable that despite the demographic evidence, women age more slowly than men.

It is important to note the source and limitations of the US national statistics as presented in Table 5-1. These data are compiled from causes of death listed on US Standard Death Certificates filled out by a physician, medical examiner, or coroner at the time of death. Determining cause of death is an inexact process and frequently opens to interpretation even with a complete autopsy; complete autopsies are infrequently done today. Even in cases where the cause of death would be clear upon autopsy, for example myocardial infarction, studies have found that death certificates frequently misattribute the cause. This is particularly an issue for chronic diseases.

be problematic. In the United States, diabetes deaths were female-biased by 25% in 1960 but male-biased by 57% in 2017. In fact, over the 57-year period between these two reports, there has been a steady gradual shift from female-to-male bias. (Other studies both from the United States and Europe reported female bias in deaths from diabetes in the first half of the twentieth century as well.) Now, however, similar male biases to those found in the United States are reported across the European Union as well as in Japan.

Changing diagnostic criteria for diabetes and variable death certificate reporting are likely contributors to these differences.

Wome n and dementia An outlier in the pattern of virtually complete female dominance in resistance to lethal disease appears to be AD, which according to 2017 US national statistics is our sixth leading cause of death and which kills women at substantially higher rates than men whether raw percentages or age-adjusted rates are used (see Table 5-1). That is, US women currently die more than twice as often as men from AD both because they live longer and because they are generally more susceptible. In comparing the 2017 to the 1960 data in Table 5-1, the percentage of total deaths reported due to AD (called senile psychosis in 1960) increased more than 250-fold for men and more than 150-fold for women over this 57-year period. As diagnostic criteria for AD were not well established in 1960, AD was dramatically

underdiagnosed then and so very few deaths were attributed to AD. Thus, the 1960 data are not interpretable. A more accurate portrayal of what AD means at present on American death certificates is probably “AD and other dementias,” which is how causes of death are categorized in the United Kingdom. For UK women, AD and other dementias have now surpassed heart disease as the number one cause of death, whereas for men it is now number five.

The current female bias in US deaths from AD is consistent with a large body of data from the rest of the developed world. In Japan and across Europe, the age-adjusted sex ratio of AD deaths is similar to the United States. Figure 5-5, which summarizes 31 independent studies from across Europe, shows the relative prevalence of AD as it accelerates with age in each gender. Thus, as populations become older, AD will likely become more and more female-biased.

FIGURE 5-5. Relation of age and gender to prevalence of Alzheimer disease. Summarized from 31 studies from across Europe. (Data from Alzheimer’s Europe.)

Sex hormones, health, and disease The pattern of women’s increased susceptibility to dementias in addition to their consistently increased resistance to most

other fatal diseases relative to men, provokes speculation about the role of sex hormones in health and disease. This has been a fraught topic in aging research at least since the late nineteenth century when French-American physiologist Charles-Édouard Brown-Séquard began injecting himself with a cocktail of macerated dog and guinea pig testicles and subsequently proclaimed that he was rejuvenated in both mind and body.

Sex hormones such as testosterone, estrogens, and progestins decline with age in both sexes, although male testosterone decline is considerably more gradual than the relatively abrupt change across the menopausal transition in women. That restoring these hormones to youthful levels will have a generalized rejuvenating effect is a plausible hypothesis. Hormone replacement for women is reviewed in Chapter 36. Data from observational epidemiology and laboratory rodent studies suggested that replacing female hormones might lead to multiple health benefits. However, such hormonal therapy does not enhance longevity and has mixed effects on various age- related diseases. Hormone replacement for men is reviewed in Chapter 97. It has limited benefits on age-related conditions in normal older men.

The reverse is also plausible. That is, one could equally reasonably speculate that declining hormone levels with age are an adaptive response to reduce hormonally-induced adverse health effects with increasing age.

Returning hormones to youthful levels, according to this hypothesis, may actually cause harm. Indeed, some historical information from the complete removal of gonadal hormones is provocative. For instance, a review of longevity records for 81 eunuchs employed as guards or servants of the royal court of Korea during the seventeenth and eighteenth centuries found that eunuchs lived on average 20 years longer than intact men of similar rank and status—a result notable mainly for the magnitude of the difference. These findings echo a previous study comparing nearly 300 castrated men with more than 700 intact controls who lived in the same institution for the intellectually disabled in the United States in the early twentieth century. This study found not only a large (> 13-year) difference in life expectancy favoring the castrated men but also a bigger survival advantage the earlier- in-life surgery was performed. Whether these studies have any relevance to men living with modern hygiene, diets, and medical monitoring is of course not clear.

The United States has been particularly well studied regarding how gender interacts with nonbiological determinants of health such as income, education, race, health habits, or access to medical care to influence longevity. This work has been motivated by a desire to understand why despite spending far more on health care than any other country, US life expectancy—especially among women—increasingly lags behind most other high-income countries.

As noted earlier, the gender gap in life expectancy in the United States grew rapidly from about 1950 to around 1980 and has been steadily shrinking since the early 1980s (see Figure 5-3). This pattern is due to a more rapid gain in women’s life expectancy relative to men’s prior to the early 1980s followed by a slower gain thereafter. Specifically, between 1985 and 2017, life expectancy of US women increased by only 3.2 years compared with 5.2 years for men. Although life expectancy of neither gender grew as rapidly as in many other high-income countries, the growth for women was particularly slow—only 50%, 55%, and 73% the rate of Japanese, French, and Swedish women, respectively. Compare that with the equivalent figures for men. US men’s life expectancy grew 13% faster than Japanese men’s, 78% and 88% as fast as French and Swedish men.

A useful tool for assessing whether this national pattern could be due to inequalities in health within the United States is a county-by-county analysis. Not only are life expectancies and mortality rates available for each of the 3143 counties in the United States, so are data on income, racial composition, education level, and a host of other variables potentially informative for understanding the reasons underlying observed health disparities. There is tremendous variability among counties across the United States in all these variables. For instance, per capita income varies by more than sixfold from the poorest to the richest county, and the life expectancy gap between the longest- and shortest-lived counties is nearly 18 years for men and 13 years for women. This gap is greater than the life expectancy gap between Sweden and Nicaragua. Reiterating the larger historical and international perspective presented earlier, despite this striking variation among US counties, female life expectancy exceeded male life expectancy in every county for every year between 1960 and the present.

Several interesting patterns appear in such an analysis. First, variability among county life expectancies has been consistently greater for men than women since at least 1960. Second, life expectancy inequalities within each

gender were smallest in the early 1980s when the gap between genders was at its maximum. Since then, within-gender inequalities have steadily risen for both sexes.

An astonishing finding has been that while the most advantaged counties have continued a steady increase in life expectancy for both sexes, there has been little change in life expectancy over the past 25 years for the least advantaged counties. This is particularly true for women for whom more than 42% of counties in the United States showed no increase in women’s life expectancy whatsoever across the entire 25-year period. Furthermore, nearly 10% of counties showed a significant decrease. Analogous figures for men reveal that fewer than 5% of counties showed no increase and fewer than 1% showed a decrease. A separate county-by-county study traced mortality rates (rather than life expectancy) from the early 1990s through 2006 and found similar results. Average mortality rates fell by 9.8% over that period for men and only 1.5% for women. Male mortality rate actually increased in only 3.4% of counties, whereas women’s mortality rate increased in almost 43% of counties! In sum then, although national US averages continue to show steady gains in life expectancy during the past 25 years, for a significant fraction of women there have been no gains—or even losses—in life expectancy over that time period.

First, mortality due to cardiovascular disease has been falling steadily for both sexes for over 60 years. As mentioned previously, this should be considered a major medical and public health triumph. During the period— roughly 1960 to 1980—when the gender gap in life expectancy was increasing, men were more frequently dying from lung cancer and chronic respiratory diseases than women. Since then as the gender gap has been shrinking, reduction in cardiovascular disease has continued although at a slower rate for women relative to men, and the relative rate of increase in deaths from lung cancer and chronic respiratory diseases has risen. Second, that pattern was particularly marked in counties in which women lost life expectancy in recent years. Clearly these patterns, as with the international patterns, reflect differences in current and past smoking behavior.

Beyond that, there is a puzzling geographic component above and beyond obvious socioeconomic factors. Most counties with increased women’s mortality were in the South, or in counties in the West with a significant

proportion of Native American residents. Local diets would be one obvious place to look for clues to the reasons for this geographic component.

Possibly more interesting than what variables were associated with decreasing life expectancy, are variables that were not. No simple correlations were found, for instance, between change in life expectancy and per capita income, educational attainment, percent of adults who were obese, availability of primary care providers, or proportion of the population lacking health insurance.

If instead of focusing on the counties that did worse over time, we focus on the ones that did better, which after all was the overwhelming number of counties for men and the majority for women, we find more of the expected explanatory factors. The two most significant associations with improved men’s survival were percent of adults with a college degree and percent of Hispanic residents. The Hispanic effect is due to the so-called Hispanic paradox, the observation that Hispanic people of both sexes live longer than White people of equivalent socioeconomic status. Still significant, but somewhat less strongly associated, were population density (the higher, the better), and median household income. Similarly, in counties in which women’s health improved over these study years, significant associations were seen with higher proportion of Hispanic people, higher proportion with college degrees, higher population density, and higher median household income. For neither sex was obesity or obvious medical care factors, such as percent of the population with health insurance or number of primary care physicians, statistically involved.

It is important to understand that the lack of statistical association between a socioeconomic or behavior factor and increasing versus declining survival in a county-by-county study does not indicate that a particular factor is unimportant for health or survival. For example, many studies have identified obesity as a significant contributor to poor health. The lack of association with obesity described above just means that a county-by-county analysis is too crude a tool to pick up a likely obesity effect.

The trend in the United States for women to gain less than men in life expectancy over time is particularly apparent if one examines differing education levels and ethnicities. Education generally can be considered almost a miracle drug for improved health and life expectancy regardless of ethnicity. For instance, among White Americans, the impact of having 16 years or more of education compared with having not completed high school

was a difference in life expectancy of 10 years for women and 13 years for men. To emphasize the magnitude of this education effect, it is comparably greater than the magnitude of life expectancy difference between Sweden and Paraguay. Education is hypothesized to exert its impact via better health habits, better ability to deal with stress, and more effective management of chronic conditions. More disturbing is the impact of low education. White women and men with less than a high school diploma actually lived about 5 and 3 years less, respectively, in 2008 than they did in 1990! Puzzlingly, this temporal decline in life expectancy for poorly educated Americans was not seen in African-American or Hispanic populations. In fact, in those ethnic groups life expectancy rose over that time period for all education levels, including those not completing high school.

In sum, health disparities within the United States are generally larger for men than women, but a substantially larger fraction of women than men are showing worse health now compared with 25 years ago.

As robust and widespread as is women’s survival advantage over men, equally robust, widespread, and puzzling, is men’s health advantage over women. Although women live longer than men everywhere, women also display greater overall rates of physical illness and functional limitations than men from adolescence throughout life. In the United States, for instance, women make more doctor visits, spend more days in hospital, miss more work due to illness, and take more medications than do men. Women also self-report more functional limitations and are overrepresented relative to their proportion of the population in residential care facilities.

This health-survival paradox is a worldwide phenomenon. In most of the world’s 187 countries, unlike in the United States, women’s life expectancy is increasing slightly faster than men’s. Also, increasing faster in women than men is the number of unhealthy years they live. One measure of ill health is “years living with disability (YLD),” which is the severity-adjusted prevalence of disability. Across countries of the world per capita YLD is generally higher for women than for men, particularly at young and middle ages. Thus the additional unhealthy years lived by women compared to men are not just those at the end of life. Additionally, self-reported health surveys of people over 50 years from the US and Europe revealed that despite more men than women being overweight and currently smoking, women in all

countries were more likely to have functional difficulties or disabling conditions. Similarly consistent differences were found in a comparative study of the United States, Jamaica, Malaysia, and Bangladesh, in which participants were asked about their ability to perform a variety of tasks, such as walk a certain distance, bend over, or climb stairs (Figure 5-6).

FIGURE 5-6. Self-reported health across several countries. Proportion of respondents reporting fair-to-poor ability to perform these tasks. (Reproduced with permission from Rahman O, Strauss J, Gertler P, et al: Gender differences in adult health: an international comparison.

One hypothesis to explain the health-survival paradox is that women are more attentive to physical discomfort and more willing to seek medical attention when they perceive it. However, empirical evidence to support such an explanation is uneven and sometimes contradictory. Also, if this hypothesis is valid, it would have to be a worldwide phenomenon rather than a cultural feature of wealthy, Western countries. Figure 5-6 shows that the same patterns obtain in poor, culturally diverse countries such as Jamaica,

Malaysia, and Bangladesh. A second plausible hypothesis is that because men die at higher rates than women throughout life, ill men are more likely to die than ill women. Thus the surviving men will be more highly selected for health and vigor than surviving women. If this sex-selection hypothesis is valid, one would predict that the sex differences in various health metrics would increase with age as more and more ill men die while more and more ill women survived. As intriguing as is this hypothesis, several large cross- national studies have failed to find such predicted divergence in health status with age. They find instead a relatively constant male health superiority throughout life.

The ubiquity of these health differences between the sexes begs for a biological explanation. One of the most consistent findings among dozens of studies investigating sex-based morbidity differences is that women are subject to more bone and joint diseases, including idiopathic back pain and osteoarthritis. Chronic pain can limit activities and cause sufferers to seek medical attention. In addition, it can have more far-reaching, secondary health consequences from sequelae such as sleep deprivation and chronic stress. So, a plausible, if partial, biological hypothesis for the health- survival paradox may be sex differences in joint components such as cartilage and ligaments. Uterine connective tissue undergoes extensive remodeling and increasing elasticity during pregnancy under the influence of various reproductive hormones. Could it be that a side effect of the responsiveness of women’s cartilage, tendons, ligaments, and muscle to female reproductive hormones is an increased susceptibility of women to joint instability and resultant inflammation and pain? Provocatively, female athletes in sports such as soccer and basketball are 5 to 10 times more likely to suffer anterior cruciate ligament knee injuries than male athletes, and most are from noncontact events. Also, the prevalence of idiopathic knee osteoarthritis is similar in men and women prior to menopause, but much greater in women after menopause, again suggesting a hormonal influence on joint health. Women also tend to have more robust inflammatory and immune responses than men, perhaps helping to account for their greater resistance to infectious diseases, and also greater susceptibility to autoimmune and inflammatory joint diseases such as osteo- and rheumatoid arthritis. Taken together, these sex differences may contribute to the health-survival paradox.

Several robust features of human biology emerge from considering sex differences in health and longevity. Most particularly, women appear more resistant than men to multiple fatal diseases, acquiring them at lower rates and/or later in life. Women also appear to be more resistant to a range of infectious diseases from early in life. A notable exception to this pattern is AD and other dementias, to which women are more susceptible than men worldwide. Despite the broad survival advantage, women are more likely to suffer from physical ailments than men later in life even controlling for age effects. It is tempting to hypothesize that differential lifetime exposure to sex hormones contributes to both the positive and negative sex differences. Yet to date, no simple answers on how lifetime sex hormone exposure relates to diseases and disabilities of later life have materialized. In the United States, there is a puzzling trend over the past several decades for women to gain life expectancy at a slower rate than men, and some groups of disadvantaged women are even shorter-lived today than they were decades ago. Learning more about sex difference in health and longevity will be critical to determining how to reduce health disparities in both sexes.

Since the US National Institutes of Health (NIH) Revitalization Act of 1993, women have been required to be adequately represented in NIH- funded clinical studies. Today, roughly half of clinical research participants are women. However, similar attention has not been paid to sex balance in studies with laboratory animals or cells, which are heavily male-biased.

Mechanistic understanding of health and disease relies to a large extent on studies of laboratory animals or cells. In May 2014, the NIH issued a policy statement promising to redress this imbalance through program oversight and review, as well as through collaboration with publishers. One desired outcome of this new direction would be a better understanding of biological sex differences in health. Ultimately, would it not be desirable that men live as long as women and women achieve the lifetime health of men?

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Scientific progress in aging and geriatrics has led to longer life expectancy, improved quality of life, and many advancements in geriatric medicine.

Unfortunately, these benefits are not equally distributed across populations. Lower life expectancy, higher age-related disease incidence including Alzheimer disease, chronic disease burden, and worse health care quality and access disproportionately affect historically disenfranchised groups in the United States—which include but are not limited to racial and ethnic minorities, persons living in rural areas or who are socioeconomically disadvantaged, and sexual and gender minorities. Such health differences are broadly referred to as health disparities, and across the life course these negative health impacts are often compounded, exerting a cumulative influence on age-related health outcomes in older adults.

Getting to the root causes of health disparities requires a well-rounded understanding of the social/environmental, behavioral/psychological, and biological processes involved and how they interrelate. We often have a better understanding of geriatric conditions from a biological and sometimes behavioral vantage point, yet less often do we understand how unequal exposure to disadvantaged social and environmental contexts drives health disparities. Frailty risk, for example, is shaped by biological (female sex) and behavioral (physical activity level and cognitive status) factors along with social and environmental factors, such as access to safe spaces within

which to exercise or financial resources to wear proper footwear for safe exercise. However, social and environmental factors are frequently overlooked in key clinical and research domains.

Social determinants of health are the conditions within which we live, grow, work, play, and age that impact health. They are particularly salient in the development and reinforcement of health disparities, playing a role in an estimated 80% of health outcomes. They include factors related to financial wealth and stability, education, the social and community context, the neighborhood and built environment, and health care access and quality.

Social determinants of health exert influence at individual, family, community, organizational, and policy levels.

It is important to recognize that social determinants of health affect the health of older adult populations. Having an awareness of the mounting evidence on these complex factors, along with being equipped with a strong conceptual, will help geriatricians and other clinicians to recognize and respond effectively to social factors that drive health disparities later in life. This chapter provides a practical foundation for defining and understanding social determinants, health disparities, and health equity as they relate to the health of older adults. While this chapter provides many examples pertaining to the United States, the underlying themes apply globally even if their manifestation and consequences are unique by country and region. Both a historical lens and a life course approach are applied to deepen understanding of the fundamental causes of health disparities. Interventions to foster health equity across individual, community, and policy levels are presented to illustrate real-world approaches to applying this knowledge.

Understanding the key concepts of social determinants of health, health disparities, and health equity, and how they are interrelated is necessary for untangling the historical and contemporary forces that shape health for older adults and the multilevel interventions sought to foster equitable outcomes.

Social determinants of health are the conditions in daily life that impact health. They include the social, economic, physical, and environmental factors that shape everyday lives, and the opportunities and barriers to health

older people may experience. Examples of social determinants of health can include the lack of access to quality education; economic stability commonly tied to employment and income; neighborhood and built environment factors like housing, safety, and access to healthy food options; and the social and community context such as challenges due to discrimination. Social determinants of health can also influence the nature of care delivery, and care delivery can further influence health outcomes—creating a compounding effect. Domains of the social determinants of health are shown in Figure 6-1, as adapted from the Centers for Disease Control and Prevention Model.

FIGURE 6-1. Social determinants of health operate within and interact across all levels of the social ecological model.

Some social determinants, such as air pollution contributing to asthma and related exacerbations, have a clear, direct pathway to health outcomes. However, many social determinants operate indirectly to affect health; for example, chronic exposure to social and environmental stressors can be linked to disproportionate rates of respiratory and cardiovascular conditions. Thanks to new targeted funding efforts, an understanding of these indirect pathways is an active area of investigation, with the hopes of making new mechanistic discoveries that explain the link between social determinants and adverse health outcomes.

Social determinants of health can often originate from systems and structures, yet they influence persons and families. The social ecological model provides a helpful visual for appreciating that individuals are situated within a larger context and shaped by these cross-cutting social determinants of health. Social determinants of health can operate within and interact across levels of society (the individual, organization, community, public) as depicted in Figure 6-1. For example, when considering fall prevention strategies for older adults, home modifications may not be an affordable or feasible option for persons who are not home-owners; and though conversations on fall prevention may be operating on a person or individual level, consideration of rental agreements may function at an interpersonal and organizational level, access to affordable housing may occur at a community level, and patterns in home-ownership may be impacted by public policy.

Health disparities are differences in health outcomes driven by unjust, inequitable causes that negatively affect a population or groups of individuals. The presence and persistence of health disparities require understanding their sources and addressing their occurrence. Though health disparities have long existed in the United States, groundbreaking reports, including the 1984 Department of Health and Human Services Report, “Health, United States, 1983,” and the 2003 Institute of Medicine Report “Unequal Treatment: Confronting Racial and Ethnic Disparities” brought broader attention to these inequities by highlighting the social and structural health system factors involved.

Older adults may experience age-related health disparities that result from unjust, inequitable access to aging-specific care, supports, and services. They may experience the accumulation of health disparities across the lifespan, resulting in long-standing and new negative health outcomes. Within the context of aging, the National Institute on Aging (NIA) provides a framework for understanding the environmental, sociocultural, behavioral, and biological factors that shape health and lead to health disparities across the lifespan (Figure 6-2). The NIA framework provides nested classifications for each factor, helping us to consider some of the potential underlying drivers of health at each level—and to also consider the timing and influence of each on health across the lifespan.

Though health disparities often exist for historically disenfranchised populations (eg, Indigenous, Black, or rural populations), a person’s group membership or identity itself does not create health disparities. However, these individuals may be disproportionately impacted or intentionally targeted by systemic, contextual, and relational forces that result in health disparities. To illustrate this point, a common misconception is that race is a risk factor for poor health—for example, that Black identity directly leads to early mortality. However, the true driver in this association is the systemic racism operating at multiple levels that results in the development and perpetuation of a health disparity, for example, shaping access to resources needed for health.

Race is a social construct. It is not a biological construct. Yet, this erroneous perception of race as a biological construct remains pervasive

FIGURE 6-2. The National Institute on Aging health disparities framework helps to recognize the variety of reasons why health disparities exist. (Reproduced with permission from Hill CV, Pérez-Stable EJ, Anderson NA, et al: The National Institute on Aging Health Disparities Research Framework. Ethn Dis. 2015;25(3):245–254.)

need for better medical education and training, and the need for wider efforts to address the structural factors that promulgate such errors.

Health equity is the assurance of the condition of optimal health for all people, centering those who are historically disenfranchised and most vulnerable. Health equity is an ongoing process and never fully achieved; instead, it is pursued through addressing social determinants of health and reducing health disparities. Older adults should be centered as active agents and recipients of health equity conversations, as age is not an exclusionary criterion to achieve health potential.

Racism Racism, or discrimination based on race, can occur at systemic, organizational, and interpersonal levels. Often, systemic and organizational racism is referred to as “institutional racism.” Less recognized, although insidious, is “internalized racism” or the biases people carry due to larger narratives about race. Racism is experienced by many older adults of color and can often be intertwined and compounded with experiences of ageism.

Intersectionality The confluence of lifelong experiences and social identities interact in specific and individual ways that contribute to older adults’ health in late life. An intersectional lens emphasizes a more nuanced and accurate understanding of how health is shaped by the many ways people experience disadvantage. Avoiding oversimplifications, intersectionality instead takes into account that the experiences and identities of race, social class, gender, age, and more intermingle to confer a lack of privilege. It can also facilitate an understanding of how health experiences are inseparable from their multiple identities; for example, the experience of managing diabetes as an older adult will be tightly tied to experiences navigating health care settings as someone who identifies as Black or someone who identifies as non- gender conforming. Moreover, multiple overlapping identities are not experienced separately but in tandem, and disadvantage is not always simply additive. For example, an older Black woman cannot leave their age, race, or gender at the door before walking into a clinical encounter, and all of these

must be considered when discussing and considering their health experiences, as depicted in Figure 6-3.

FIGURE 6-3. An intersectional lens helps to understand the overlapping nature of identities.

To develop a better understanding of the complex nature and persistence of health disparities in the United States, a brief historical review is needed. While it is not possible to capture all historical experience here, these are some of the salient examples in which history continues to have lasting effects on society. In this section, the manner in which phenomena such as colonialism, slavery, segregation, and contemporary sources of control over individuals based on skin color and other social identities continue to deny key resources to populations, affecting life, opportunity, and health is reviewed. A historical lens allows us to understand the manner in which social identities have been constructed over time. The lasting effects of these historical and contemporary forces, although described in the United States context, are perpetuated across multiple axes (eg, race, sex, gender, disability, immigrant status) and worldwide. Though manifestations and impacts may be unique by country and region, the resultant health disparities often share similar features.

Colonialism has resulted in ongoing repercussions on Indigenous health and may be considered a distal or underlying determinant of Indigenous health—in other words, a cause of the causes of health determinants. Not only can colonialism be linked to Indigenous health, as an underlying determinant and source of historical trauma, but it paved the way for the continued displacement and marginalization of Indigenous persons, systemic underfunding of health resources (including the Indian Health Services), failure to recognize Indigenous health traditions, and erasure of the successes of Indigenous communities, including self-governance and self- determination.

For African-Americans, a history of slavery followed by sharecropping, segregation, and state-sponsored oppression (eg, redlining and lending bias) have shaped the opportunities for housing, employment, education, and health across families and neighborhoods. For example, notably yet often overlooked is the intense violence against and systematic removal of supports for freed slaves during the post-Civil War Reconstruction era followed by 10 decades of subservience and segregation. This, in part, fueled the Great Migration of African-Americans out of Southern States from approximately 1916 to 1970 for risky jobs in other areas of the country with little to no family wealth or education. Some narratives portray slavery, segregation, and racism as a thing of the past, or if present, a rare interpersonal occurrence. These narratives forget recent history along with contemporary events that demonstrate persistence and long-lasting harms of racist and often state-sponsored tools that oppress opportunity and health.

Disadvantage is perpetuated by a history of discriminatory practices (including in the workplace and community), and denial of rights and certain protections against many groups including women, persons with disabilities, persons from immigrant backgrounds, and lesbian, gay, bisexual, and transgender (LGBT+) people, generating health disparities over the lifespan. For example, LGBT+ people have long-faced legal discrimination: the ways in which family and partnerships have been defined block access to health insurance in safety net programs like Medicaid as well as social security, employment, and veteran benefits. Home equity is often the main source of family wealth, yet discriminatory lending practices contribute to widening wealth gaps. These lending practices have often discriminated based on place, race or ethnicity, and immigrant status. For example, mortgage discrimination in the form of redlining or denying credit, has origins which

trace back to the 1930s, dispersing and segregating communities in addition to damaging home equity. Furthermore, the practice of reverse redlining during the housing crisis of the 2000s has garnered attention, where risky, high-cost subprime loans were disproportionately offered to borrowers in Black and Latinx neighborhoods. Given the allocation of resources by place, and the manner in which neighborhood and health are tied together, not only does displacement, redlining, and mortgage bias impact opportunity, but it also hurts health.

While concentration of populations within certain regions and neighborhoods may not be, in itself, a negative phenomenon, restriction of movement of these persons based on their social identity represents discriminatory policies and practices. Moreover, these regions and neighborhoods are more likely to be zoned in manners that allow industrial and mixed environments, resulting in poorer air and water quality, less access to food and green space, and greater likelihood of highway construction. Another modern phenomenon is the mass incarceration of disproportionately non-White populations, which can contribute to family separation, poverty and trauma, and subsequent poor health.

A historical lens can help us understand that the “mistrust” toward health care systems is in fact the absence of earned trust.

Additionally, in a disturbingly persistent manner, health care professionals have wielded medicine as a tool of oppression against specific groups. For example, there is a long history of people with disabilities being involuntarily sterilized, a practice which was upheld in a 1927 Supreme Court ruling and after which resulted in forcible sterilization of roughly 70,000 people, often disproportionately women, racial minorities, and poorer people.

The United States is undergoing major population shifts. In less than 20 years, people 65 years and older will outnumber those under the age of 18.

Soon after, groups considered to be racial and ethnic minorities will outnumber White populations. And by 2060, persons 65 years and older will have grown nearly 69% larger and represent 23% of the total population, with White persons representing half of the entire population 65 years and older (see Chapter 2).

Other notable trends include the rising numbers of adults 65 years and older remaining in the labor force and the decrease in poverty rates among older adults. However, poverty rates remain around 10% and are nearly double for racial and ethnic minorities. The US population is becoming more diverse, and correspondingly so are older adults. This diversity can be seen in the growing number of older adults who identify as Black, Indigenous, Latinx, for example—all identities which have experienced historical disenfranchisement and therefore may experience corresponding consequences on health. A nonexhaustive review of population trends for historically disenfranchised groups and unique health considerations is presented below; yet further investigation is merited with caution to the harms that can occur with assuming individuals may conform to and experience wider phenomena.

Provider-older adult interactions create opportunity for social determinants of health screening. At a minimum, this should include: self-identified race and ethnicity, employment and education, use of tobacco/alcohol/drugs, car and firearm safety, domestic violence history, marital and children status, housing status, social supports, and information on neighborhood and built environment.

Geriatricians and teams have opportunities to identify unmet needs and provide immediate resources or act as a bridge to community-based services that have the potential to create meaningful change in the health and quality of life of older adults. Social determinants of health screening also has the potential to encourage person-centered, trauma-informed care; improve diagnosis and reduce missed diagnosis; provide resources that increase medication adherence; and potentially avoid unnecessary health care utilization.

When conducting assessments that consider social determinants of health, there are important considerations to prevent common errors and maximize organizational efficacy:

a conversation within your organization on the timing and location for social needs screening and intervention delivery; determine team process for conducting assessment and intervention; tailor screening tools to the local older adult population and known unmet needs; determine process for matching older adults with local resources based on their self-identified unmet needs and establish relationships with corresponding community- based organizations; and develop a process for documentation and follow- up.

A preliminary understanding of available community-based supports and services (CBSS) is needed prior to making recommendations, with examples specific to the United States context provided in Table 6-2. CBSS aim to meet educational, wellness, nutritional, counseling, financial, safety, and housing needs, yet CBSS availability and quality vary greatly. For example, CBSS in rural areas may provide services to older adults across several counties, requiring providers and older adults to drive long distances for access. While more than 20% of older adults regularly access CBSS, there may be unmet needs among these adults and those not yet connected to CBSS.

TABLE 6-2 ¦ EXAMPLES OF ORGANIZATIONS PROVIDING COMMUNITY-BASED SERVICES AND SUPPORTS

CBBS for older adults were first expanded by the 1965 passage of the Older Americans Act (OAA). Funding is allocated to services in at least these areas: supportive services, congregate and home-delivered meals, preventive health, caregiver support, abuse prevention, and ombudsman. The OAA made possible the Administration on Aging (AoA) and corresponding state-specific Area Agencies on Aging (AAAs). AAAs operate on federal, state, and municipal funding, though they also rely on private funding sources.

Over 3 million older adults rely on meal services, caregiver supports, home care, adult day services, and transportation on a regular basis, with over 9 million receiving these services intermittently. These services result in less meals skipped and greater nutrition, social contact, decreased caregiver burden, delays to institutionalization, among other outcomes.

Resources vary by state and region. In some areas, waiting lists for these services are long.

A 75-year-old veteran, Marshall, who self-identifies as African-American is being evaluated in a memory clinic for cognitive concerns. Upon evaluation in clinic, Marshall is found to have significant visuospatial and short-term memory impairment. He also shared that he recently had several, “fender benders”, raising concerns regarding his driving safety. Dr. M., the geriatrician evaluating Marshall, asks if he has any family that could be contacted as they have determined that Marshall can no longer drive safely.

Marshall says there is only one person he knows they could call. Dr. M. reviews Marshall’s social history, sees that he is married, and asks if Marshall knows his wife’s number, assuming this is the individual he would like to have called. Marshall grabs his car keys off the desk, yells “No!”, and storms out of the office. Security cannot locate Marshall in a timely manner. On his way home, Marshall suffered minor injuries in a motor vehicle accident and is admitted to the hospital for treatment.

Several days later, on rounds, Dr. M. swings by Marshall’s room. While Marshall is getting a CT scan, there is a visitor in the room. Dr. M. asks if he is a friend of Marshall’s, and the visitor informs Dr. M. that he is Marshall’s partner. Dr. M. learns that although Marshall was married and had several children, he identified as queer his entire life and suffered considerable discrimination and harm during his years of service in the military over questions of his sexual orientation. Due to the discrimination he encountered, he limited his social circle, made very few friends, and lost contact with much of his family, leaving him isolated. About 5 years ago, he decided to come out to his children as he wanted to spend the end of his life with his partner, but this resulted in him losing contact with all of his children. The visitor asks Dr. M. why he was not called when Marshall had his first visit, so he could come and take him home.

Reflection questions: (1) How does intersectionality play a role in this case study, specifically in the way Marshall may interact with the health care system? (2) When providing care to older adults, what are the risks of labels or assumptions?

Laura Block and W. Ryan Powell contributed equally and are co-first authors of this chapter.

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Mental Status and Neurologic Examination Assessment of Decisional Capacity and Competencies Prevention and Screening

Low Vision: Assessment and Rehabilitation Hearing Loss: Assessment and Management GENDER AND SEXUALITY

The importance of perspective is the basis of any discussion of decision making. All decisions are viewed through the lens of the decision maker. In medicine, decisions can be viewed from many perspectives including the patients, families, the clinicians, the health care system, and even society.

This array of lenses with differing motivations and incentives can lead to widely disparate decisions. For example, a doctor may recommend an expensive medication such as a new chemotherapy in the interest of helping a patient live longer. The patient on the other hand may not be singularly focused on survival and/or may find the side effects intolerable. The family caregiver may be overwhelmed in coordinating medical care. The health care system in which the physician works may be eager to reap the reimbursements of an infusion associated with the medicine. Meanwhile, society may be concerned that the high costs and marginal benefits of the medication provides relatively little value (higher costs relative to the benefits) to society as a whole.

This chapter is not meant to be an exhaustive discussion of the science of decision making. As such, a detailed discussion of the contemporary politics and economics of cost effectiveness, insurance design, cost sharing, and other issues essential to understanding decision making at the health care

system or societal level are beyond the scope of this chapter. Rather, this chapter will take a clinical perspective focusing on the challenges and opportunities for patients, surrogate decision makers, clinicians, and others involved in the complicated decision making with older adults.

Modern medical decision making sits largely on an ethical foundation. Grounded firmly on the ethical principle of autonomy, emphasis on a patient- centered approach has been rising since the early twentieth century when courts began charging physicians with battery for performing operations to which patients did not consent. While judges have softened this to negligence over time, court cases in the United States, including those involving Karen Ann Quinlan, Nancy Cruzan, and Terri Schiavo, and acts of US Congress such as the Patient Self-Determination Act continue to affirm a patient’s and/or surrogate’s right to determine their medical treatment plan.

The movement, often called “patient-centered care” is based on an underlying assumption that people make decisions in a normative and rational way. Normative decision theories, such as expected utility theory, are based on an ideal that people can approach decisions rationally and are able to cognitively weigh the risks and benefits of various interventions to make a good decision. However, there is a disconnection between the rhetoric of “good” decision making and the reality of decision making.

Descriptive theories of decision making demonstrate that humans are subject to cognitive biases that cause decisions to deviate from what would be predicted by the normative/rational approach. One famous descriptive theory is prospect theory developed by Dan Kahneman and Amos Tversky. One aspect of this theory demonstrates that the way options are framed influences the decisions that are made. In a classic example, respondents were asked to imagine that an unusual flu-like disease is expected to kill 600 people. They were given the choice of two alternative programs which were mathematically identical according to the normative expected utility theory.

In option A 200 people will be saved, and in option B there is one-third probability that 600 people will be saved and two-thirds probability that no one will be saved. When the options are presented as gains (“people will be saved”), 72% of the respondents chose to save the 200 people rather than take riskier option B. However, if options were presented as a loss (“400 people dying”), 78% of the respondents chose the riskier option B. This experiment elegantly demonstrates how decisions can change drastically simply based on framing; that when options are presented as gains, people tend to be risk averse, and when options are presented as losses, people tend to be risk seeking. Of note, the respondents to that survey were medical professionals highlighting the point that clinicians and patients alike are equally susceptible to these biases. Prospect theory is just one example from

the growing field of behavioral economics (also referred to as cognitive psychology). The influences and applications of these theories to modern medical decision making is an active area of research.

The challenge for all clinicians and patients making decisions at the bedside is in finding ways to build a bridge between the legal and ethical mandate to promote patient-centered care and informed consent and the behavioral aspects where decision making, including related to future decision making, is not always rational. Ultimately, good decision making involves elicitation of the patients’ priorities among general, often competing health outcome domains—such as longevity versus comfort/symptom relief— to assure that these preferences drive all evaluation and management decisions.

Clinical decision making for older adults, including diagnosis, treatment, and desired outcomes, is different and more challenging than it is for younger patients. Generally, the primary goal of medical care in younger adult patients is diagnosis of the disease causing the presenting symptoms, signs, and/or laboratory abnormalities. Treatment is targeted toward the pathophysiologic mechanisms deemed responsible for the disease. Survival is generally paramount. Relevant clinical outcomes are determined by the specific diseases and often include cure if the disease is acute.

In older adults, the conventional disease-specific approach is not optimal for several reasons. First, age-related physiologic changes in most organ systems affect diagnostic test interpretation and responses to treatments.

Additionally, the average 75-year-old suffers from 3.5 chronic diseases. With multiple coexisting chronic diseases, there is a less consistent relationship between the pathology, the disease, and the clinical manifestations. One disease may obscure the presentation of another and treatment of one may increase the severity of another. With multiple coexisting diseases, it becomes difficult, and often impossible, to assess the severity of individual diseases and to ascribe health and/or functional status to specific disease processes.

Second, many distressing symptoms or impairments among older persons, such as pain, dizziness, fatigue, sleep problems, sensory impairments, and

gait disorders cannot be ascribed to a single disease; instead, they result from the accumulated effect of physical, psychological, social, environmental, and other factors. A clinical focus solely on diagnosing and treating discrete diseases may lead to expensive diagnostic testing with inconclusive results. Worse, it may even harm if unnecessary and invasive interventions are not aligned with patient preferences. While clinicians may be reluctant to treat symptoms in younger and middle-aged patients without a specific diagnosis, treatment focused on improving symptoms in older patients with multimorbidity is often appropriate, because comfort and function are often the primary goals among this population.

Third, diagnostic test characteristics may be altered by age and comorbidity, making selection and interpretation of tests more complicated than for younger patients. Furthermore, both the benefits and harms of treatment regimens may differ in the face of age-related physiologic changes and multimorbidity. A good example of this is found in cancer screening where the false positive rate of many tests often increase as people age.

Further, the true positives may be detecting things (eg, low-grade prostate cancer) that might have been better left undiagnosed. Consequently, more consideration needs to be taken regarding the individual patient characteristics and their treatment goals.

Fourth, older patients vary in the importance they place on potential health outcomes. When asked, older persons can prioritize among competing goals of increased survival, comfort, cognitive function, and physical function, and in certain instances may opt for comfort or function over survival. Optimal clinical decision making in the care of older patients includes (a) the articulation of patient preferences or goals of care; (b) the estimation of prognosis based on disease and non-disease factors; and (c) clarification of the role that impairments (ie, cognitive, mobility, sensory) and non-disease-specific factors have on the attainment of these preferences and goals. The multiplicity of impairments and diseases; the contribution of psychological, social, cultural, and environmental factors to health conditions; the enhanced likelihood of harm as well as benefit from many interventions; and the variability in goals and preferences all combine to make clinical decision making in the care of older persons very complex.

Fifth, clinical decision making is further complicated in older patients because other persons, including the spouse/partner, adult children, other relatives, and significant others, are often actively involved, particularly

when cognitive impairment is present. Involvement of family of choice is helpful and often crucial, since they may provide additional sources of information, facilitate adherence to treatment recommendations, and offer both emotional and instrumental support. Up to 70% of older adults lose the capacity to make decisions prior to death and require surrogates. Conflicts may arise, however, when goals of the patient and family differ. Navigating the need for patient confidentiality and family involvement, between independence and support, and between patient and family goals is a constant challenge. When based on an understanding of these factors, however, the clinical care of older persons is both effective and immensely gratifying.

Clinicians are tasked with evaluating a patient including performing a history and physical examination, initiating a diagnostic workup when appropriate, and determining what medically reasonable options are appropriate given the patient’s unique situation. Clinicians must then explore the patient’s goals and share in the decision making to assure that the chosen treatments align with the patient’s goals. Especially if a family member or care partner is a part of the clinical encounter, the clinician should identify preferences for who and how other individuals should be involved in decision making.

The clinical interview is an important element of the decision-making process. It can be used to establish a diagnosis and monitor treatment and prognosis. The altered, often attenuated, presentation of diseases, the coexistence of multiple processes, and the underreporting of symptoms in older patients mandate a reordering of the importance of various components of the history. The chief complaint, the cornerstone of history-taking in younger patients, has decreased relevance in older persons.

Social history is of paramount importance in the care of older adults. Knowing a person’s living arrangements and financial situation as well as how they make decisions is essential. Especially as older adults experience cognitive or functional impairment that increasingly involves caregiver support, it is critical to identify preferences or need for a surrogate medical decision maker.

The clinical history of older persons should also include assessments of cognitive function, affect, and mood (depressive symptoms). It is particularly

important to observe for concerns related to undiagnosed dementia or cognitive impairment that may affect the person’s decision-making capacity. These topics are discussed in detail in Chapters 9 and 10. Briefly, mood and affect can be screened for easily with tools such as the two-question depressive screen. (In the past month, have you been sad, blue, or down in the dumps? Have you lost interest in most things or been unable to enjoy them?) More formal, systematic assessments should be undertaken if there is any question of depression (see Chapter 65).

The physical examination in older persons differs from younger persons as well. The purpose of the physical examination in younger persons is primarily to diagnose specific diseases. The physical examination in older persons, however, also serves to identify treatable impairments such as muscle weakness, gait instability, or sensory impairments, and to directly observe the performance of key functional tasks.

While the content of the physical examination will be much the same for older, as for younger patients, given time constraints, high-yield, relevant, but less traditional, examination items should take precedence. For example, during day 5 of a hospitalization, it is likely more important to see if a patient can sit up or stand than to listen to the heart sounds. Other high-yield examination elements might include postural blood pressure, cognitive status, hearing and vision limitations including inspection of ear canal for cerumen, visual acuity, and foot examination.

Diagnostic testing is often used to support decision making. However, even this poses additional challenges among older adults. The value of a diagnostic test is best determined by considering whether the test is accurate, the target disorder is dangerous if left undiagnosed, the test has acceptable risks, and effective treatment exists. All of these criteria are relevant as older patients often have multiple health conditions and limited life expectancy changing both the accuracy and value of diagnostic testing. Also, because older adults vary in the emphasis they place on outcomes other than mortality, even a good diagnostic test may not be appropriate for an individual patient.

Deciding whether a diagnostic test is important requires consideration of its ability to change the probability of disease prior to test completion

(called the pretest probability of the target disorder) to a probability of the disease after test completion (called the posttest probability). As for the physical examination, the coexistence of diseases and age-related changes may affect the sensitivity, specificity, predictive value, and interpretability of laboratory, imaging, and other ancillary tests. Consequently, most tests have lower value among older adults. In addition, age-referenced normal values and ranges have been developed for some, albeit, not most laboratory tests.

In older persons, there are additional issues to consider including the ability of the patient to complete the test and whether the test does more good than harm. A patient with significant gait impairment, for example, is not going to be able to complete an exercise stress test. And, it may not be appropriate to consider a particular diagnostic test in someone with multiple comorbidities and poor quality of life if the purpose of that testing does not align with the patient’s goals. For example, a diagnosis of dyslipidemia is not clinically relevant in someone with advanced cancer.

In deciding whether to perform laboratory, imaging, or other ancillary tests, the clinician should consider the issues outlined in Table 7-1 and the principles described in this chapter. This decision process is illustrated for the example of noninvasive imaging for carotid stenosis. Consider for example, an 80-year-old patient who presents with a transient ischemic attack. A carotid Doppler ultrasound is ordered and reveals greater than 70% stenosis of the carotid artery on the affected side. Magnetic resonance angiography (MRA) is ordered and the patient’s family wants to discuss whether to proceed with the test. Before the MRA is done, several issues should be considered in addition to ensuring that surgery is available and effective in your setting. Would the patient consider carotid endarterectomy? If the answer is no, further diagnostic testing is not warranted. Are there significant comorbidities or contraindications to the surgery? For example, if a patient has advanced dementia and poor functional status, the benefits of surgery would be questionable both because of their competing morbidities limiting the time through which they might benefit and the greater difficulty they might have in participating in the perioperative care and rehabilitation.

If surgery might be contemplated, then it is appropriate to determine whether there are accurate and reliable tests for diagnosing carotid stenosis available in your setting.

TABLE 7-1 ¦ ISSUES TO CONSIDER IN DECIDING WHETHER TO PERFORM A DIAGNOSTIC TEST AND HOW TO INTERPRET RESULTS

A recent systematic review of the accuracy of noninvasive imaging tests compared with intra-arterial angiography for significant carotid stenosis in symptomatic patients can help with the last question noted above. Forty-one studies including 2541 patients were included in this review. The accuracy of the four imaging techniques for diagnosing significant carotid stenosis is provided in Table 7-2. For diagnosing 70% to 99% stenosis, the specificity was lowest for MRA and Doppler ultrasonography. Thus, MRA may result in inappropriate surgery in up to one in seven patients. This systematic review suggests that noninvasive testing cannot appropriately be used to recommend carotid endarterectomy. Patients should be made aware that they will likely require intra-arterial angiography, which does carry a small but real risk of complications. Unless the clinician considers patient outcome goals and risk

preferences as well as the accuracy of the diagnostic tests, some patients will have surgery who do not need or desire it and some medically treated patients will have preventable strokes.

TABLE 7-2 ¦ ACCURACY OF NONINVASIVE IMAGING TECHNIQUES FOR DIAGNOSING 70% TO 99% CAROTID STENOSIS COMPARED WITH INTRA-ARTERIAL ANGIOGRAPHY

Patient-centered care dictates that clinical decision making should occur within the context of individual preferences and goals. Ascertainment of these preferences, which are known to vary among older patients and among patients with multiple health conditions, should occur early and often (see Chapter 7). Older persons rarely volunteer their preferences. Active solicitation of priorities and preferences, therefore, needs to be an integral part of the patient and family interview. Good patient-centered care does not mean that the doctor tells the patient what to do. This is the paternalism that modern ethics and Western legal systems have largely overturned. At the same time, good patient-centered care does not entail putting a smorgasbord of options in front of a person and telling them to choose—an approach that has even been called patient abandonment. Rather, decisions should be

shared between the clinicians and their patients. Clinicians bring expertise in the medical information and patients bring expertise in themselves and what is important to them. Then, a shared decision is less about information provision and more about a conversation between two experts.

A body of research suggests that patients are not adequately informed when receiving medical interventions. A large national survey across nine different medical conditions demonstrated that patients scored low on their knowledge, even if they had received those procedures. Perhaps even more concerning is the literature that patients often receive care that they would not want. Many patients, especially older patients, have difficulty in choosing among a set of treatment options. Rather than having patients make every specific treatment choice, which is difficult and often not feasible for the large number of medical decisions that older adults face, encouraging patients to prioritize among different outcome domains allows them to express directly what is most important to them regarding their health care.

The elicitation of priorities among general, often competing health outcome domains, including longevity, comfort/symptom relief, cognitive functioning and physical functioning should ideally drive all evaluation and management decisions.

The process of goal elicitation can be complicated and requires a clinician adept in handling the communication challenges that will arise. First, the setting for the discussion may need to be adapted to the specific impairments of some older persons. Impairments in hearing, visual acuity, and cognition, each prevalent among older persons, mandate a quiet, well-lit, and unhurried setting in order to have a meaningful discussion. Multiple encounters may be required to complete the history and to gather the necessary information. While the patient remains the key informant, the discussion often needs to be supplemented by information obtained from the patient’s family of choice, and/or other care providers, particularly if the older person has cognitive impairment.

Second, the process of goal elicitation can be emotional. Sometimes, a patient or family may articulate a goal that is just not feasible given their situation (eg, continuing to live alone in their home). Here, the task of the clinician is in helping the patient redefine goals that are feasible. This can be a difficult and emotional conversation for all involved. Often, to help

patients define their goals, they must enter into the complicated discussion of prognosis. An area of active research is in improving clinicians’ communication skills with patients to facilitate these patient-centered discussions.

ACP and goals of care conversations can occur in various settings, including ambulatory care, emergency departments, inpatient hospitalization, post- acute care, and long-term care. ACP conversations often involve patients, individuals serving as surrogate decision makers, and health care practitioners. While some ACP conversations are brief, other conversations may benefit from the structure and preparation in family meetings. For older adults, the ACP process is well-suited to outpatient, longitudinal care and

should unfold over time; however it also often occurs around changes in medical conditions, new diagnoses, changes in functional or cognitive status, or care transitions such as hospitalization or admission to residential care.

Health care providers should have phrases for introducing a desire to discuss ACP, such as, “We’re taking a step back to talk about the big picture with your care. I do this with all my patients so I can provide you with the kind of care you would want.” The introduction should aim to normalize the process and emphasize to the patient and family the goal of providing medical care that is aligned with their goals. Then, clinicians and teams can engage individuals and their families by introducing key concepts over time, as outlined in Table 7-3. Each concept can be discussed individually and often in 5 minutes or less, based on time constraints and patient needs.

TABLE 7-3 ¦ ADVANCE CARE PLANNING IS A MULTISTEP PROCESS

Many clinicians provide comprehensive care for older adults with multiple chronic conditions and functional limitations. Throughout an individual’s journey of living with advanced illness, there are opportunities for ongoing conversations. Developed by the Ariadne Labs, the Serious Illness Conversation Guide helps clinicians conduct successful conversations in an intentional sequence. The guide is readily available and provides

patient-tested language. Given that discussing ACP may bring up strong emotions, there are communication training programs (ie, brief videos from VitalTalk) to help clinicians navigate these emotions to best support their patients (see Table 7-4).

TABLE 7-4 ¦ ADVANCE CARE PLANNING RESOURCES

Person and family-centered tools can assist patients with knowledge and decision making related to ACP. Because ACP conversations can be a personnel- and time-intensive process, helping patients and families begin this process on their own is useful. Health care teams can systematically incorporate the use of patient-centered tools to help engage patients before meeting to have these conversations. Table 7-4 summarizes resources that are available for practical use by patients and their families. For example, the Stanford Letter Project has videos of diverse individuals sharing their wishes with family or their doctor. The PREPARE website demonstrates multiple steps of ACP, such as deciding on flexibility in decision making for surrogate decision makers (see Table 7-4).

ACP conversations will be more successful with consideration of the individual’s family, cultural, spiritual, and religious norms. In a study of patient-reported barriers to high-quality end-of-life care, patients from multiethnic backgrounds identified: (1) finance/health insurance barriers, (2) doctor behaviors, (3) communication chasm between doctors and patients,

(4) family beliefs/behaviors, (5) health system barriers, and (6) cultural/religious barriers. While the clinician should never assume that all members of a group have the same beliefs, knowledge of some of the norms can aid in the future medical care planning discussions and decision making. Additionally, literacy and language-appropriate documents may enhance ACP. Clinicians cannot predict what an individual patient wants or is even willing to discuss. The only way to know is to ask in a nonjudgmental, patient-centered manner. Questions to help understand an individual’s perspective could include: “Are there any cultural, spiritual, or religious factors that I should know about as we talk about the care you would want if you got sicker?” and “How do your religious or spiritual beliefs influence your wishes for your medical care near the end of your life?”

As noted above, decision making with older adults is challenging in many ways. For most, life comes with multimorbidity and functional decline and the traditional disease-focused models do not work. While a lucky few have truly compressed morbidity, the majority of older adults experience gradual decline, mounting morbidity, and frailty. However, underneath the challenge is a deep richness. Helping patients and families clarify their outcome goals and assuring that treatments align with those goals will never be automated by a machine. Perhaps more than anywhere else, the art and humanity of the sacred practice of medicine thrive when caring clinicians engage in decision making with older adults.

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Geriatric assessment describes the health evaluation of the older patient and emphasizes components and outcomes different from that of the standard medical evaluation. This approach recognizes that the health status of older persons is dependent upon influences beyond the manifestations of their medical conditions. Among these are social, psychological, and mental health, and environmental factors. Geriatric assessment also places high value upon functional status, both as a dimension to be evaluated and as an outcome to be improved or maintained. Frailty is a related construct that is increasingly being measured for prognostic and occasionally for outcome purposes.

Although in the strictest sense geriatric assessment is a diagnostic process, many use the term to include both evaluation and management. Moreover, geriatric assessment is sometimes used to refer to evaluation by the individual clinician and at other times is used to refer to a more interdisciplinary process, comprehensive geriatric assessment (CGA) and adaptations by various specialties.

This chapter is divided into four components: (1) geriatric assessment by the individual clinician, with an emphasis on the outpatient setting; (2) a strategic approach to geriatric assessment for the practicing clinician; (3) CGA and evidence for its effectiveness; and (4) lessons learned from geriatric assessment that have been applied to health care delivery of older persons.

Geriatric assessment (Figure 8-1) by the individual clinician extends beyond the traditional disease-oriented medical evaluation of older persons’ health to include assessment of cognitive, affective, social, economic, environmental, spiritual, functional, and frailty status, as well as a discussion of patient preferences regarding advance care planning. Assessment instruments can be used to guide these evaluations but do not substitute for clinical skills and judgment, including the skill of eliciting important items from the patient’s history and physical examination. Systematic assessment of the multiple domains noted above ensures that the evaluation is comprehensive. Some clinicians may prefer to rely on less formal questions to probe into potential problems but the responses to these should be documented in the patient’s record.

Geriatric assessment differs according to the setting where the patient is being evaluated. In the hospital setting, the initial assessment is usually directed at the acute medical problem that precipitated the hospitalization and change from baseline. As the patient begins to recover and plans are initiated for discharge, other components (eg, social support, environment) assume increasing importance in the assessment. The inpatient setting can be problematic for geriatric assessment because of the rapidly changing status of several key dimensions. For example, a patient may temporarily become “dependent” on all measures of functional status when acutely ill and gradually improve prior to discharge. Because patients may overestimate their functional status based on their previous level of functioning, direct observational methods (eg, by nurses or rehabilitation therapists) provide a more accurate assessment. The patient’s full potential to participate in rehabilitation may not be known until near the time of discharge.

Nursing home geriatric assessment requires that attention be directed to selected aspects of assessment such as nutritional status and self-care activities. Other components such as functional status at the instrumental activities of daily living level (eg, shopping, meal preparation) are less relevant in this setting. Geriatric assessment conducted in the patient’s home provides an opportunity for assessment of environmental factors (eg, home

safety) and may yield different insights into functional status (eg, cleanliness of the home).

Because the primary site of most clinicians’ practices is the office setting, assessment techniques are described primarily for this setting. When appropriate, differing or particularly important information about assessment in other settings is added.

In addition to the standard medical history and physical examination, the clinician should systematically search for specific conditions that are common among older persons and that might have considerable impact on function. In the course of the traditional medical evaluation, these problems may go unnoticed because older patients fail to report them spontaneously. For example, they may not recognize that falling is a treatable medical problem. They may also be embarrassed to mention problems with maintaining urinary continence. Finally, they may believe that some symptoms, such as hearing loss, are normal aspects of aging that cannot be helped.

Visual impairment is a common and often underreported problem in the older population. The four major eye diseases (cataract, age-related macular degeneration, diabetic retinopathy, and glaucoma) increase in prevalence with age. Moreover, developing presbyopia is virtually universal and the vast majority of older persons require eyeglasses. Visual impairment has been associated with increased risk of falls, functional and cognitive decline, immobility, and depression. The high rates of vision disorders and their associated sequelae, the brevity of the screening process, and the treatments available for visual impairment justify screening for visual impairment.

However, the revised 2016 US Preventive Services Task Force (USPSTF) guidelines concluded that there is insufficient evidence to determine whether screening older adults for vision impairment improves functional outcomes.

The standard method of screening for problems with visual acuity is the Snellen eye chart, which requires the patient to stand 20 ft from the chart and read letters, using corrective lenses. Patients fail the screen if they are unable to read all the letters on the 20/40 line with their eyeglasses (best corrected

vision). A home-printable vision screening test for telemedicine has been validated.

Hearing impairment is among the most common medical conditions reported by older persons, affecting approximately one-third of those age 65 or older. Hearing impairment is associated with reduced cognitive, emotional, social, and physical function, leading to increased hospitalizations and delirium. The use of amplification devices has led to improved functional status and quality of life in older persons.

Screening for hearing loss can be accomplished by several methods (Table 8-1). The most accurate of these is the Welch Allyn AudioScope 3 (Welch Allyn, Inc., Skaneateles Falls, NY), a handheld otoscope with a built- in audiometer. The AudioScope 3 can be set at several different levels of intensity, but should be set at 40 dB to evaluate hearing in older persons. A pretone at 60 dB is delivered and then four tones (500, 1000, 2000, and 4000 Hz) at 40 dB are delivered. Patients fail the screening if they are unable to hear either the 1000- or 2000-Hz frequency in both ears or both the 1000- and 2000-Hz frequencies in one ear, indicating the need for formal audiometric testing.

TABLE 8-1 ¦ SIMPLE TESTS OF HEARING LOSS

A simple alternative is based on the patient’s own subjective report of hearing loss. A self-reported hearing loss question involves asking patients a single question of “Do you have difficulty hearing?” An affirmative answer is then considered to be a positive test for hearing loss, and patients should be referred to an audiologist.

Another alternative is the whispered voice test, which is administered by whispering three to six random words (numbers, words, or letters) at a set

distance (6, 8, 12, or 24 inches) from the person’s ear and then asking the patient to repeat the words. The examiner should be positioned behind the person to prevent speech reading and the opposite ear should be covered or occluded during the examination. Patients fail the screening if they are unable to repeat half of the whispered words correctly.

There are several screening questionaries for hearing loss including the Hearing Handicap Inventory for the Elderly—Screening Version (HHIE-S), the Hearing Self-Assessment Questionnaire (HSAQ), and the Revised Five Minute hearing test. These screening tests are all self-administered and contain about 10 to 15 items. Although these questionnaires are brief and easy to administer, their accuracy for detecting mild hearing loss is inferior to audiometry.

A 2011 review of the evidence on screening of hearing loss in older adults found that inquiring about self-perceived hearing loss or the whisper test at 2 ft had similar rates of detecting hearing loss as the tone-emitting otoscope or formal hearing questionnaire. The most recent USPSTF review of screening concluded that there is insufficient evidence to formally recommend hearing screening for this population.

Malnutrition is a global term that encompasses many different nutritional problems that are associated with diverse health consequences. Both extremes of body weight place older people at risk for subsequent functional impairment, morbidity, and mortality. Among community-dwelling older persons, the most common nutritional disorder is obesity. In addition, a small percentage of community-dwelling older persons have energy or protein energy undernutrition, which places them at higher risk for death and functional decline. Protein energy undernutrition is defined by the presence of clinical (physical signs such as wasting, low body mass index) and biochemical (albumin or other protein) evidence of insufficient intake.

On their initial visit, patients should be asked about weight loss within the previous year (> 4% should trigger further evaluation) and patients should be weighed at every subsequent office visit. Height should also be measured on the initial visit to allow calculation of body mass index (weight in kg/[height in meters]2). Although screening for specific nutrients and

In hospitalized older persons, malnutrition has been associated with higher mortality rates, delayed functional recovery, and higher rates of nursing home use. The simplest and most practical method is for the nursing staff to report daily on the percentage of the diet that the patient is eating.

Intake can be also measured through formal calorie counts. Laboratory monitoring is less likely to be useful. Although serum albumin levels can drop acutely during inflammatory states, physiologic stress, and in response to trauma or surgical conditions, this protein has a long half-life (approximately 18 days) and may provide an idea of the patient’s baseline nutritional status. Prealbumin, which has a much shorter half-life (approximately 2 days) may be a better means of monitoring response to nutritional treatment. In the nursing home, weight loss or gain of greater than or equal to 5% in the past 30 days or greater than or equal to 10% in the last 180 days are Medicare Minimum Data Set triggers for malnutrition.

Urinary incontinence is common and estimated to affect 11% to 34% of older men and 17% to 55% of older women. Despite its high prevalence, incontinence is often underrecognized. Patients may find it embarrassing to raise the issue or they regard it as a normal aspect of aging. Urinary incontinence has been associated with depressive symptoms in older adults and is a major factor in nursing home placement. Moreover, effective treatments are available for incontinence. As a result, screening for urinary incontinence has been recognized as an indicator of quality of care.

Screening for urinary incontinence can be done with two questions: (1) “In the last year, have you ever lost your urine and gotten wet?” and if so, (2) “Have you lost urine on at least six separate days?” In a research setting, those who answered positive to both questions had high rates (79% for women and 76% for men) of urinary incontinence as determined by a clinician’s evaluation (see Chapter 47).

The 3IQ questionnaire is another brief interviewer-administered instrument with high sensitivity and specificity that has been developed to distinguish between urinary stress and urge incontinence in women in primary care settings (Table 8-2).

The Women’s Preventative Screening Initiative (WPSI) recommends annual screening for urinary incontinence, which should not be limited based on age, parity, or weight.

Over one-third of community-dwelling persons older than 65 fall every year. Falls are independently associated with functional and mobility decline.

Observing patients walking and performing balance maneuvers best assesses balance and gait disorders. Once the clinician is trained to assess gait, this evaluation can be performed while the patient is entering or leaving the examining room. Several simple tests of balance and mobility (Table 8- 3) can also be performed quickly in the office setting, including the ability to maintain a side-by-side, semi-tandem, and full-tandem stance for 10 seconds; resistance to a nudge; and stability during a 360-degree turn. Quadriceps strength can be briefly assessed by observing an older person arising from a hard armless chair without the use of his or her hands. The timed “up and go” test is a timed measure of the patient’s ability to rise from an arm chair, walk

3 m (10 ft), turn, walk back, and sit down again; those who take longer than 12 seconds to complete the test should receive further evaluation. Gait speed is also a helpful marker for recurrent falls. Patients who take more than 13 seconds to walk 10 m are more likely to have recurrent falls. The Short Physical Performance Battery incorporates chair stands; side-by-side, semi- tandem, and full-tandem stance; and gait speed to calculate a summary score that assesses quadriceps strength, balance, and gait speed.

TABLE 8-3 ¦ SIMPLE TESTS OF LOWER EXTREMITIES: STRENGTH, BALANCE, GAIT, AND FALL RISK

Polypharmacy in older patients is associated with adverse drug reactions, reduced adherence, and inappropriate medication usage. Older persons often receive care from multiple providers and fill prescriptions at several

—both prescription and nonprescription medications—to each visit for a thorough medication reconciliation and to check for potential drug-drug interactions.

Given the burden of complex comorbid disease in many older adults, it is important to balance guidelines for chronic disease management with the individual’s goals of care, as well as risk factors for adverse drug events such as cognitive impairment, frailty, and renal impairment. A “prescribing cascade” can occur when additional pharmacotherapy is initiated to treat side effects of a prescription. Each new symptom should prompt a medication review and a trial of discontinuation of the suspected agent. The Beer’s Criteria has been developed and periodically updated by the American Geriatrics Society to assist clinicians with identifying and avoiding potentially inappropriate medications for the older adults.

Because the prevalence of Alzheimer disease, other dementias, and cognitive impairment rises considerably with advancing age, the yield of screening for cognitive impairment increases with age. Although in 2020, the USPSTF concluded that there is insufficient evidence on the balance of benefits and harms of screening for cognitive impairment, clinicians should assess cognition when there is suspicion of impairment or when conducting a Medicare Annual Wellness Visit. Several screens are available for clinical use (Table 8-4) and some can be performed in 5 minutes or less (eg, the Mini-Cog, which combines three-item recall and clock drawing; the Memory Impairment Screen [MIS]; and the General Practitioner Assessment of Cognition [GPCOG]). Longer screens that are commonly used include the Mini-Mental State Examination (MMSE), which takes 7 to 10 minutes to administer and must be purchased for use, the Montreal Cognitive Assessment (MoCA), which takes 10 to 15 minutes to administer and requires paid certification, and the Rowland Universal Dementia Assessment Scale (RUDAS), which takes 10 minutes to administer.

TABLE 8-4 ¦ COMMONLY USED COGNITIVE SCREENS

Although normal results on these tests vastly reduce the probability of dementia and abnormal results increase the likelihood that the patient has dementia, these tests are not diagnostic for dementia and normal results do not exclude the possibility of this disorder. Patients who have abnormal

findings on a cognitive screening test should receive more in-depth evaluation of memory, language, visual–spatial, and executive function.

Among hospitalized patients, mental status should be assessed at the time of hospital admission and then periodically because older persons are especially prone to develop delirium during the hospital stay. Abnormal findings on the mental status examination in hospitalized patients must be interpreted in the context of change from baseline and the clinical situation.

The Confusion Assessment Method, which has an Intensive Care Unit version, provides a guide to interpreting such changes and assesses acute change or fluctuating course, inattention, disorganized thinking, and altered level of consciousness. The Ultra Brief two-item bedside screen asks patients to list the days of the week backward and what day of the week it is. Older persons who develop delirium should have their cognition reassessed several weeks later (see Chapter 58).

Major depression and other affective disorders are common among the older persons and are likely underdiagnosed owing to underreported symptoms, atypical presentations, or comorbid cognitive impairment or other neurologic diseases such as Parkinson disease. These treatable disorders are associated with increased disability, health care utilization, morbidity, and mortality, and decreased quality of life. A brief two-item screening inquiry, the Patient Health Questionnaire-2 (PHQ-2), asks about the frequency of depressed mood and anhedonia over the past 2 weeks, and, if positive, can prompt further screening by completing the full nine-item survey, PHQ-9. The PHQ-9 is commonly used to detect and monitor depression symptoms in older adults and provides a reliable and valid measure of depression severity. A score of more than 10 has a sensitivity of 88% and a specificity of 88% for major depression. In patients with underlying cognitive impairment who may lack insight into their mood, caregivers can be asked to complete the Cornell Depression Scale for Dementia. A score of greater than or equal to 6 has a sensitivity of 93% and a specificity of 97% for depression in dementia.

Measurement of functional status is an essential component of the assessment of older persons. The patient’s ability to function can be viewed as a summary measure of the overall impact of health conditions in the context of

his or her environment and social support system. In older persons, the ability to function consistent with their personal lifestyle values should be an important consideration in all care planning. Therefore, changes in functional status should prompt further diagnostic evaluation and intervention. An early indicator of impending functional disability is self-perceived difficulty with performing functional tasks. Measurement of functional status is also valuable in monitoring response to treatment and may provide prognostic information that will help plan for long-term care.

Functional status can be assessed at three levels: basic activities of daily living (BADLs), instrumental or intermediate activities of daily living (IADLs), and advanced activities of daily living (AADLs). BADLs refer to self-care tasks such as bathing, dressing, toileting, continence, grooming, feeding, and transferring. Instrumental activities of daily living refer to the ability to maintain an independent household such as shopping for groceries, driving or using public transportation, using the telephone, meal preparation, housework, home repair, laundry, taking medications, and handling finances. AADLs refer to the ability to fulfill societal, community, and family roles as well as participate in recreational or occupational tasks. These advanced activities vary considerably from individual to individual but may be valuable in monitoring functional status prior to the development of disability.

Questions that ask about specific BADL and IADL functions have also been incorporated into a variety of more generic health-related quality-of- life instruments (eg, the Medical Outcomes Study Short-Form 36 and its shorter version, the SF-12). Some AADLs (eg, exercise and leisure time physical activity) can also be ascertained by using standardized instruments, but open-ended questions about how older persons spend their days might provide a better assessment of function in healthier older persons.

Physical function can also be assessed by directly observing the performance of functional tasks. Instruments have been developed for use in ambulatory, nursing home, and hospital settings, and predictive validity has been demonstrated for many. Some studies have demonstrated that combining self-reported functional with performance-based measures can provide more refined prognostic information than either method alone.

Frailty is a clinical syndrome where dysregulation of multiple physiologic systems reaches a critical threshold which results in a physiologic state of heightened vulnerability. Frailty has been conceptualized as physical (phenotypic or syndromic) or as deficit accumulation (due to cumulative comorbidities). Frail patients are at higher risk of adverse clinical outcomes including falls, fractures, hospitalizations, surgical complications, disability and dependency, and mortality.

More than 60 frailty instruments have been developed and used for a variety of purposes, most commonly for risk assessment for adverse clinical outcomes. These instruments variably assess the following domains: physical function/disability, physical activity, cognition, comorbidity, weight loss, and other domains (eg, social, sensory, demographic). The Clinical Frailty Scale (CFS) (Figure 8-2) is an effective and rapid way to assess frailty in older adults. There are nine levels of functionality described ranging from “very fit” or level 1 to “terminally ill” or level 9. The CFS utilizes criteria such as activity levels, ADL/IADL dependence, and life expectancy. Other commonly used instruments include the Physical Frailty Phenotype (Table 8- 5) and the Vulnerable Elders Survey-13 (Table 8-6).

TABLE 8-5 ¦ PHYSICAL FRAILTY PHENOTYPE

TABLE 8-6 ¦ VULNERABLE ELDERS SURVEY (VES 13)

Effective preventative strategies for decreasing frailty have been identified including interventions geared toward maintaining muscle mass and strength and consuming a Mediterranean diet. When frailty is identified, it is important to review advance care planning to ensure patient’s goals and values will be considered moving forward.

The composition of the older patient’s social support structure can be assessed by asking about their relationships, such as with family, friends, neighbors, and caregivers, as well as the quality of these relationships in the social history. For frail older persons, the availability of assistance from family and friends is frequently the determining factor of whether a functionally dependent older person remains at home or is institutionalized. If dependency is noted during functional assessment, then the clinician should inquire as to who provides help for specific BADL and IADL functions and whether these persons are paid or voluntary help. Even in healthier older persons, it is valuable to raise the question of who would be available to help if the patient becomes ill. Early identification of social support needs may prompt planning to develop resources when the necessity arises. For vulnerable older adults, clinicians should be mindful of signs of elder abuse,

neglect, or exploitation, and if suspected, are mandated to report cases to Adult Protective Services.

During the COVID-19 pandemic, social isolation played a more profound role in decreasing the quality of life, increasing mood symptoms, and worsening cognitive function of many older adults. While widespread adoption of a single tool for assessing for social isolation has not been applied clinically, research tools including the Lubben Social Network Scale (12-item instrument to assess for social isolation in older adults) as well as the UCLA Loneliness Scale (20-item scale designed to measure feelings of loneliness and social isolation) can be considered. However, the time needed to administer these tools has limited their widespread use in clinical medicine.

Many older adults live on fixed incomes, and the rising costs of medical expenses coupled with that of paid caregivers and residential facilities can cause financial hardship that may manifest as medication nonadherence, weight loss, or the appearance of self-neglect. Although some clinicians feel uncomfortable assessing the economic status of their patients, inquiring about financial stress including food insecurities may prompt referral to social work or other agencies and help prevent the associated poor health outcomes.

Furthermore, insurance status is routinely collected by office staff and a patient’s income can be assessed and eligibility determined for state or local benefits (eg, in-home supportive services through Medicaid or Veteran’s benefits). For the frail and functionally impaired older adult, clinicians should partner with patients and families to provide anticipatory guidance regarding the resources that may be required to pay for care at home or in a residential facility.

Environmental assessment encompasses two dimensions, the safety of the home environment and the adequacy of the patient’s access to needed personal and medical services. Particularly among frail individuals and those with mobility and balance problems, the home environment should be assessed for safety with particular attention to fall risk. Although most physicians do not personally conduct environmental assessments, the Centers

for Disease Control and Prevention has developed a home safety checklist (https://www.cdc.gov/steadi/pdf/check_for_safety_brochure-a.pdf) that patients and their families can complete. For those receiving home health services, in-home safety inspections can be performed, including recommendations for installation of adaptive devices such as shower bars and raised toilet seats. The benefits of such services was further supported by the CAPABLE trial, which showed that home visits provided by occupational therapists and registered nurses and home modifications to address functional goals led to decreases in disability in low-income community-dwelling older adults compared to those who received home visits solely for social purposes by a research assistant.

Older persons who begin to develop IADL dependencies should be evaluated for the geographic proximity of necessary services such as grocery shopping and banking, their need for use of such services, and their ability to use these services in their current living situations. Increasingly, some of these services are available online though many older persons, particularly those who are frail, do not feel comfortable using the Internet to purchase services. Older drivers are at increased risk for motor vehicle accidents secondary to functional impairments, medications, and medical conditions.

Spirituality, whether affiliated with a formal religious denomination or nonreligious intangible elements, has been recognized as an important influence on health and quality of life. Frequent attendance of religious services has been associated with lower health care utilization and mortality rates. Formal instruments for assessing spirituality have been developed, such as the FICA or the HOPE questions for spiritual assessment, but these are not widely used in clinical practice. Simply asking older persons whether religion or spirituality is important to them may provide insights that may tailor their individual care. Especially in hospital settings, involvement of pastoral care may be valuable in supporting the patient and in framing medical decisions in the context of the patient’s personal belief system.

Although goals of care and advance directives both solicit patient preferences, they are conceptually different. Goals of care are patient- directed wishes for either a state of well-being to be attained (eg, sleep through the night without being awakened by pain) or maintained (eg, continue volunteer work) or specific accomplishments (eg, being able to walk again after a stroke). Goals may be short term or long term but should be realistic with potential for attainment. Particularly in frail older persons and those with multimorbidity, goals are overarching, spanning multiple diseases, and are often nonmedical (eg, spending quality time with family, attending a grandchild’s wedding). When goals are elicited by health care professionals, care planning can be focused toward attaining them, and attainment can be measured. For goals that are not attained, alternative strategies can be employed, or goals can be modified or discarded in favor of new goals.

In contrast, advance directives focus on wishes for care in the context of serious, usually acute, illness. An Advance Health Care Directive enables patients to ensure that their health care wishes are known in advance and considered if for any reason they are unable to speak for themselves. It also allows a patient to appoint a Durable Power of Attorney, or health care proxy, who will have legal authority to make health care decisions in the event that patient is incapacitated or whereupon the patient grants such authority. Discussions of advance directives are especially important for older patients and should be initiated early on, to discuss the patients’ goals and preferences for care should they experience progressive cognitive impairment or acute illness. Physicians can assist patients by focusing on patients’ overall goals of care, rather than specific detailed interventions, and incorporating these goals into the patients’ current clinical situation. A particularly important time to discuss such preferences is prior to surgery because of the possibility of surgical complications or postoperative delirium, which may preclude discussions following the procedure. Such discussions should be revisited any time there are significant changes in a patient’s medical condition and a better understanding about prognosis becomes available, as patients often revise their thoughts about the burdens and benefits of treatment. Cultural differences regarding preferences for advance directives and end-of-life care should be recognized and respected. Overall, patients are receptive and grateful for discussion of their goals and preferences for care, and increasingly advanced directive counseling

discussions have been incentivized and recognized in quality of care measures, with various tools being developed to support advanced care planning in practice. Online tools, such as prepareforyourcare.org, have also allowed patients and families to take a proactive approach to reflecting on their goals and wishes.

Much of the information needed to assess older persons can be obtained from old records, other professional or nonprofessional staff, or by self-report from patients or family members completing forms, rather than from direct clinician interview. This efficiency allows the clinician to spend more time following up on issues that are detected, conducting the physical

Pre-visit questionnaires can be completed by the patient or proxy before the clinical encounter. These questionnaires typically gather information on past medical history, medications, preventive measures, and functional status, including information on who helps when the patient is functionally dependent. As a result, they can markedly reduce the time needed to conduct an initial assessment and can ensure a consistent level of comprehensiveness for every patient. By including validated screening instruments, they can also be used to case-find individuals with common geriatric syndromes. With the advance of technology and electronic health records, there is the potential for patients, families, or caregivers to complete such questionnaires electronically, and the information obtained can be seamlessly integrated into the electronic health record.

A second method of streamlining the office visit is to delegate the administration of screening instruments for many of the important geriatric problems to trained office staff. Thus, the clinician may spend a short period of time reviewing the results of these screens and then decide which dimensions, if any, need greater evaluation. However, office staff must be properly trained to administer these instruments, which can be quite time- consuming (10–20 minutes). This time must be taken from other office tasks and the cost of screening may be considerable.

One approach integrates screening for geriatric conditions into the office workflow and then uses structured electronic health record templates to guide more detailed assessment and guide the clinician toward appropriate management steps. This approach has been demonstrated to improve the

quality of care for falls, dementia, and urinary incontinence as well as patient-reported outcomes for falls and incontinence. Portions of the structured visit note can be delegated to office staff, further increasing efficiency.

This approach to increasing efficiency can be applied to many geriatric conditions. Table 8-7 shows a strategy that optimizes the clinician’s time by employing the most efficient methods to obtain assessment information. The initial step provides the clinician with basic information that can quickly be processed and followed with more extensive data gathering, when appropriate. Such a strategy begins with the pre-visit questionnaire and then is supplemented by information obtained by office staff. These two data sources are reviewed by the clinician and additional information is obtained from the patient and family at the time of the visit.

TABLE 8-7 ¦ STRATEGY FOR EFFICIENT OFFICE-BASED ASSESSMENT

During the COVID-19 pandemic, most health care systems transitioned to telehealth services to continue providing care for older patients while decreasing their potential exposure to the virus. In 1 year, telehealth services increased by over 20% among older adults including telephone calls, video visits, and digital messaging. Yet, approximately 38% of older adults are simply not ready for telehealth.

Many older adults have difficulties with technology including not having adequate access to telephones or internet, poor hearing and vision, as well as having dementia or cognitive impairment. Thus, it is important to screen for the capabilities to utilize telehealth. A social work referral may provide additional state or locally funded resources such as a free phone or cellphone plan.

Often, a family member or hired caregiver needs to assist the older adult in setting up telehealth visits. In assisted-living facilities, staff may need to obtain the right equipment and ensure preparedness for the appointment.

In situations where a physical examination and other diagnostic studies are required to obtain a diagnosis, telehealth visits are not recommended. Additionally, it is a challenge to observe ambulatory status and detect subtle gait abnormalities. Thus, telephone or video visits may be more appropriate as subsequent rather than initial visits.

Medicare, state-funded Medicaid, and various private insurances have expanded services and coverage for telephone or video visits during COVID-19 but their future reimbursement is still uncertain.

CGA is a systematic evaluation of frail older persons by a team of health professionals that may uncover treatable health problems and lead to better health outcomes. This evaluation typically includes four dimensions: physical health; functional status; psychological health, including cognitive and affective status; and socioenvironmental factors. Early randomized clinical trials provided convincing evidence that such programs conducted in hospital-based and rehabilitation units, which typically required several weeks of treatment, could lead to better survival rates, improved functional status, and more desirable placement (eg, home rather than nursing home) following discharge from the hospital. Conceptually, CGA is a three-step process: (1) screening or targeting of appropriate patients, (2) assessment and development of recommendations, and (3) implementation of

recommendations, including clinician and patient adherence with recommendations. Each of these steps is essential if the process is to be successful at achieving health and functional benefits.

Within this broad conceptualization, CGA has been implemented using many different models in various health care settings (Table 8-8). Because of changes in length of hospital stays, many CGA programs rely on post- discharge and community-based assessment. Furthermore, most of the early programs focused on restorative or rehabilitative goals (tertiary prevention), whereas many newer programs are aimed at primary and secondary prevention.

TABLE 8-8 ¦ SPECTRUM OF COMPREHENSIVE GERIATRIC ASSESSMENT–LIKE INTERVENTIONS

The purpose of the first step, targeting, is to distinguish older patients who are appropriate and will benefit from CGA, rather than those who are either too sick or well to benefit. To date, no easily administered targeting criteria have been demonstrated and validated to readily identify patients who are likely to benefit from CGA in different settings. Specific strategies used by CGA programs to identify older persons who are most appropriate for CGA have included chronological age, functional disability, physical illness, geriatric conditions, psychosocial conditions, and previous or predicted high health care utilization. All of these criteria have randomized clinical trial support for their effectiveness in identifying older persons likely to benefit from CGA. However, the definitions of these criteria and the interventions that have followed have varied from study to study.

Most CGA programs exclude patients who are unlikely to benefit because of terminal illness, severe dementia, complete functional dependence, and inevitable nursing home placement. Exclusionary criteria have also included identifying older persons who are “too healthy” to benefit.

The second step of CGA, the assessment process, continues to be highly variable across programs. The types of health care professionals included in the assessment team, the content of information collected, and the types and intensity of services provided have differed in studies of the effectiveness of CGA. In many settings, the CGA process relies on a core team consisting of a physician, nurse, and social worker and, when appropriate, draws upon an extended team of various combinations of physical and occupational therapists, nutritionists, pharmacists, psychiatrists, psychologists, dentists, audiologists, podiatrists, and opticians. Although these professionals are usually on staff in hospital settings and are available in the community, access to and reimbursement for these services have limited the effectiveness of the CGA process. Frequently, the composition of the team is determined by local expertise and availability of resources rather than programmatic needs. Some CGA programs use a “virtual team” concept in which members are included as needed, assessments are conducted at different locations on different days, and conferencing is completed via telephone or electronically.

Traditionally, the various components of the evaluation are completed by different members of the team. There is considerable variability in which professional conducts the assessments. For example, the medical assessment of older persons may be conducted by a physician, nurse practitioner, or physician’s assistant. The core team may conduct only brief initial assessments or screens for some dimensions. These may be subsequently augmented with more in-depth evaluations by additional professionals. For example, a dietitian may be needed to assess dietary intake and provide recommendations; an audiologist may need to conduct a more extensive assessment of hearing loss and evaluate an older person for a hearing aid.

The process of care rendered by CGA teams can be divided into six key elements: (1) data gathering; (2) discussion among the team; (3) development of a treatment plan; (4) implementation of the treatment plan; (5) monitoring response to the treatment plan; and (6) revising the treatment plan.

Data gathe ring Standardized assessments can either use instruments developed specifically for clinical purposes or assemble standard instruments that have previously been studied for validity and reliability. The advantage of the former is that teams can customize the information being gathered to best suit the clinical needs of the program. The advantage of the latter is that patients

in the program can be compared to those in other programs. Frequently, however, these instruments were developed for research purposes and may not provide information that is helpful in the care of patients.

Discussion among team Following initial data gathering, the team meets to discuss the patient’s geriatric needs. Each conference typically begins with short discipline-specific presentations followed by interactive discussions among professionals. Sometimes additional information will need to be obtained before final recommendations can be made. The team then identifies problems that need action and might be responsive to treatment.

Development of the treatme nt plan Based upon this discussion, the team develops an initial treatment plan and goals for the patient. Whenever possible, the patient and appropriate family members should be included in the development of the treatment plan. Through techniques such as motivational interviewing, patients can be asked to identify their priorities and willingness to make changes. Based on these, care plans can be created with patients as active partners.

Some CGA programs use protocols that are triggered by specific geriatric conditions whereas others rely on the experience and clinical judgment of the team. If the number of recommendations resulting from CGA is large, they should be prioritized to focus on the major recommendations, those that are most likely to produce the desired outcomes. The urgency of recommendations must also be determined. Although some recommendations may need to be implemented immediately to confer short-term benefit such as stopping a medication that may be the cause of delirium, others may be better implemented once the patient is more stable.

At the time of the assessment, a plan for implementation of each recommendation must be developed. It needs to be determined who will assume responsibility for initiation and completion of the recommendation. Similarly, the team must establish a plan for monitoring the patient’s progress as treatment is being delivered.

Implementation of the Treatme nt Plan Options for implementation are available and include direct implementation of recommendations by the team, merely advising physicians and patients verbally or by a note in the chart, and coaching patients to approach their physicians to discuss CGA recommendations.

Monitoring To ensure that recommendations are implemented and to follow a patient’s progress, patients must be monitored directly by the CGA team or by the primary care physician. During this phase, key issues to consider are how frequently and for how long this monitoring should occur. The more intensively and the longer patients are followed, the more resource intensive the consultation becomes. In some models, the CGA team may temporarily assume primary care for several months before returning the patient to the primary care physician for ongoing care.

Revising the treatme nt plan By monitoring the patient, CGA teams can continually assess the patient’s progress toward meeting the goals established by the team. If progress is not proceeding according to expectations, the team may need to reevaluate the patient and resume the team discussion. Treatment recommendations and implementation plans may need to be revised. Again, engaging the patient is important as readiness to change or the patient’s goals may have changed. Any modifications require additional monitoring.

In virtually all studies of CGA, the process has resulted in improved detection and documentation of geriatric problems. However, such identification of problems has not always led to improved outcomes. Meta- analysis has been used to evaluate models of CGA in several settings.

Geriatric Evaluation and Management Units (GEMUs), also referred to as Acute Care of the Elderly (ACE) units, are designed to be environment friendly to older persons. Two main benefits of these units are: (1) physicians staffing the unit generally assume primary care of the patient, thus facilitating the implementation of recommendations; and (2) the availability and experience of a dedicated team of providers (eg, nurses and therapists) increase the consistency and geriatric orientation of hospital and post-acute care. Similar in concept to Cardiac Care Units (CCUs) and Stroke Units, these units assemble resources for a specific patient population. A meta- analysis of 29 trials published through 2016 found that recipients of care on inpatient units were slightly more likely (relative risk [RR] 1.06) to be living at home and less likely to be admitted to a nursing home (RR 0.80) at 3 to 12 months compared to usual care. There were benefits on mortality, functional dependence, cognitive function, or length of stay in the hospital. Of note,

earlier studies demonstrated more favorable outcomes than more recent studies suggesting that usual care for older persons in the hospital may be improving. Some programs have attempted to recreate the core elements of ACE units for hospitalized older persons who are not located on a single unit (mobile ACE services) due to logistical barriers of a dedicated physical unit.

Outside of the traditional geriatric units, many of the principles of CGA have been integrated into comanagement models. These models usually involve a geriatrician and a surgeon who share responsibility and decision making. In a meta-analysis of eight randomized trials, geriatric comanagement programs for older patients with hip fractures have shown reduced discharges to an increased level of care compared to their pre- hospitalization living situation. There was a nonsignificant trend for reduction of inpatient mortality. In another meta-analysis of 12 studies, the comanagement model had reduced length of stay and fewer complications; however, the evidence was considered to be low quality.

Studies of CGA have found inconsistent benefits for posthospital discharge programs. In one randomized trial of posthospitalization, patients who received CGA versus usual care did not show any differences in reducing functional decline, post-discharge acute care visits, or depression after 24 weeks. However, patients assigned to the intervention group were less likely to be readmitted to the hospital. A systematic review found that many of the components of CGA were parts of care transition interventions that were effective in reducing rehospitalizations and emergency department visits.

CGA programs for patients discharged to home from the emergency department were found to be effective at reducing emergency room visits and hospital admissions.

The evidence for outpatient CGA has been inconsistent. Some individual studies have shown benefit on quality of care and functional decline. There have not been benefits on hospitalization and nursing home placement.

Moreover, a meta-analysis of controlled trials found no benefit of outpatient CGA on survival.

Home assessment programs are a variation of CGA that focus primarily on preventive rather than rehabilitative services and are aimed at patients at low rather than high risk of nursing home admission. Multiple meta-analyses have found home assessments to be consistently effective in reducing functional decline (if a clinical examination is performed) as well as overall mortality among younger patients (73–78 years).

Despite unresolved issues regarding the effectiveness of CGA, the principles of CGA have been incorporated into a number of programs that have been demonstrated to be effective. These models adopt various components of CGA including targeting, assessment, and interventions.

CGA with geriatric comanagement of frail patients on nongeriatric inpatient units has shown some promise with meta-analyses demonstrating decreased length of stay and improved functional status with geriatric comanagement of frail patients on nongeriatric wards. In addition, CGA has been adapted to specialty treatment of older persons including oncology, cardiology, emergency department post-discharge management, inpatient orthopedic care, and the preoperative evaluation of older patients. As an example, CGA has been applied to patients with aortic stenosis undergoing evaluation for transcatheter aortic valve replacement (TAVR) and cancer patients undergoing chemotherapy. Elements of CGA have also been incorporated into disease management programs, including stroke and heart failure.

In summary, geriatric assessment continues to evolve as an integral component of the care of older persons. As assessment techniques become better standardized and validated, more efficient yet comprehensive approaches are possible. To date, implementation of such strategies has not occurred on a widespread basis in part due to barriers including cost, logistical implementation, training issues, and unique circumstances of different health care systems. However, as national initiatives to improve quality move forward, screening for geriatric conditions and appropriate assessment of patients who screen positive will likely gain more acceptance. Advances in technology and newer approaches to data collection have increased the ability to integrate geriatric assessment and management that could not have been possible a decade ago and further advances are likely on

the horizon. In addition, principles developed in CGA models have now been incorporated into the care of many specialties, either through geriatric comanagement models or structured geriatric assessments.

Sonja Rosen, MD, and Heather B. Schikedanz, MD, contributed to this chapter in the 7th edition and some material from that chapter has been retained here.

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The diagnosis of neurologic disease in the older adult requires recognition not only of abnormal signs and symptoms but also an understanding of what changes are expected as part of the normal aging process. To distinguish neurologic dysfunction related to disease from the neurologic changes associated with normal aging, the clinician must conduct a comprehensive mental status and neurologic examination. When establishing a neurologic diagnosis, the clinical history (ie, history of the present illness, past medical history, social habits, occupational experience, family illness, and disorders) assists the clinician in generating a differential diagnosis that can be further explored and refined by pertinent observations documented on the mental status and neurologic examinations. One of the most vital tools for the diagnosis of neurologic disorders is to perform a comprehensive neurologic examination.

The mental status assessment should evaluate cognition, emotion, and behavior. Because cognitive and affective disorders occur commonly in older adults, historical information should be obtained not only from the patient but a reliable informant such as the spouse, adult child, or caregiver. The neurologic examination should be performed on all older adults regardless of the chief complaint as up to 60% of older patients have either a primary or secondary neurologic sign or symptom. A complete mental status and neurologic examination provides the necessary data to develop reasonable diagnostic hypotheses and drive the necessary laboratory, imaging, or specialized assessments to care for the patient.

Before discussion of the individual components of the examination, it would be useful to discuss changes that are expected as part of the aging process (Table 9-1). Normal age-related changes are due to progressive and irreversible changes associated with tissue senescence and the inability of nervous system to repair and regenerate secondary to the ravages of time.

The frequency and qualitative characteristics of these changes vary from individual to individual but are present in many older adults. It is important to note that these findings are not pathologic in nature and are considered to be part of the normal aging process.

TABLE 9-1 ¦ NEUROLOGIC CHANGES ASSOCIATED WITH NORMAL AGING

Cognitive changes There continues to be a debate regarding the extent of cognitive changes associated with aging due largely to differences between cross-sectional and longitudinal study designs. When comparing older adults

to young adults on similar cognitive tasks such as the Wechsler Adult Intelligence Scale, older adults generally score lower on both performance and verbal subtests. However, when differences in performance are considered in light of motor slowing and educational attainment, these changes are less apparent. Results from cross-sectional studies imply that normal cognitive aging is characterized by nearly linear declines from early adulthood in processing speed. Longitudinal evaluation of older adults has generally demonstrated little change in verbal intelligence with aging while performance is influenced significantly by motor and processing speed.

Forgetfulness therefore is not a part of normal aging. While it may take longer to process new information and retrieve well-learned information, new learning and memory formation occurs in older adults. This is one reason why delayed recall of word lists is effective in discriminating older adults with cognitive impairment from those without.

Changes in cranial nerve function Visual and hearing changes are common in older adults. Visual acuity declines due to a number of ophthalmologic (cataracts, glaucoma) and neurologic (macular degeneration) causes. Pupillary size is typically smaller with age and pupils are less reactive to light and accommodation, forcing many older adults to use glasses for reading. There is also a restriction in eye movement in upward gaze. Also associated with aging is a decline in speech discrimination due to presbycusis, a progressive elevation in the frequency threshold for hearing. There are also age-related degenerative changes in inner ear including loss of hair cells, atrophy of stria vascularis, and thickening of the basilar membrane.

Changes in motor function There is a progressive decline in muscle bulk and strength associated with aging. Most of the muscle loss is found in the intrinsic muscles of the hands and feet, and around the shoulder. There is a weakening of the abdominal muscles which may accentuate spinal lordosis and contribute to low back pain. Muscle loss is associated with denervation on electrophysiologic studies and with type II atrophy on muscle biopsy. In addition to loss of strength and muscle bulk, changes in the speed and coordination of movement increases with advancing age. These changes may interfere with activities of daily living (dressing, putting away the dishes, getting out of a chair) and recreation activities (golfing, shuffleboard). On examination, these changes may manifest as mild bradykinesia and dysmetria on finger-nose-finger and heel-shin tests.

Changes in sensory function By far the most common change will be the loss of vibration perception in the lower extremities and to a lesser extent position sense may be affected as well. As vibration sensation becomes impaired in lower extremities, there is an ascending pattern, from toe to ankle and knee. Pain and temperature sensation is also diminished in the older adult, but in the absence of a pathologic cause, usually does not elicit much symptomatology. The mild impairment in position sense often manifests as a mild swaying during the Romberg test.

Changes in gait and station Changes in gait and station in old age may be attributed in part to decreased muscle strength, weakening of abdominal muscles, arthritis and degenerative joint disease, diminished vibration and position sense, impairment in motor speed, and coordination. These changes make it more difficult for older adults to tandem, heel or toe walk for extended periods of time. Despite this, many older adults have adequate postural righting reflexes and are not likely to spontaneously fall (distinct from what is seen in Parkinson disease). Instead, polypharmacy, drug-drug interactions, and adverse effects from medications are significant risk factors for falls.

Changes in deep tendon reflexes The most common age-associated change is the depression or loss of the Achilles tendon reflex. Other reflexes usually remain present but are diminished in response. An extensor plantar response (Babinski sign) is not a normal age-related change but instead is always associated with some underlying pathology in the upper motor neuron. In patients in which a Babinski cannot be elicited (eg, patient with lower extremities amputation), an alternative test would be to elicit a Hoffman’s sign. To elicit this sign, the examiner has to flick the fingernail of the middle finger down. A “positive” sign is obtained when there is involuntary flexion and adduction of the thumb and or flexion of the index finger. This can also be seen in upper motor neuron disease (ie, amyotrophic lateral sclerosis).

There is no substitution for a carefully elicited history detailing the onset, duration, quality, and location of symptoms. The history helps the clinician develop a differential diagnosis and focus on the neurologic examination. The history will also guide the formulation of diagnostic evaluations and develop a treatment plan. In addition, a compassionate clinician will be able

to build a trusting relationship with the patient that will enhance patient adherence to medical recommendations. As a general comment, to avoid bias, it is often useful to gather historical facts de novo and not read other records or review laboratory studies such as imaging before taking the history and performing the physical examination. Here we discuss two aspects of neurologic history taking—from the patient, and when available from an informant.

An accurate history requires that absolute attention is paid to detail, both verbal (what the patient is saying) and nonverbal (what the patient is doing). This is critical to match the chief complaint with the patient’s body language. For example, someone complaining about severe low back pain that appears to be sitting comfortably in the chair may raise suspicion. Likewise, the older adult who offers no complaints but is noted to have a rest tremor should prompt more detailed questioning. One of the most important attributes of a skilled clinician is the ability to be a good listener and to focus in on critical historical points. The most effective historians gather information by a combination of open-ended and structured questions. After asking the patient why they are in office and offer a chance to express concerns or worries in their own words, specific topics can be addressed by focused questioning.

Another important aspect of the history is to elicit qualitative and quantitative aspects of the chief complaint. It is not enough to elicit a history of a “headache” or “pain.” What are the characteristics of the complaint, when did it start, what makes it better, what makes it worse? Has this happened before, and if so, did it present in the same fashion? Use simple scales to quantify the extent of the complaint by asking, “On a scale of 1 to 10, with 10 being the worst (symptom)….” These qualities can help focus a differential diagnosis and help to build trust with the patient. For example, the onset and characteristics of the headache might guide the clinician in the diagnosis and workup of headaches that may need an emergent intervention. For instance, a “thunderclap” severe headache associated with meningeal signs on examination may be suggestive of a subarachnoid hemorrhage or reversible cerebral vasoconstriction syndrome while a chronic headache with no “red flags” on history or examination might be a primary benign headache that needs no emergent intervention.

In many instances, gathering information from a third party will be invaluable in determining the onset, duration, and extent of the neurologic problem. In cases where there are problems with cognition or alertness, this may be the only reliable way to gather information. Again, using both open-ended and structured questions will often provide the clinician with important information about the chief complaint and assist in the development of a differential diagnosis. If possible, interviewing the informant in an area separate from the patient may provide a true picture of what is transpiring.

The elements of a comprehensive mental status examination include observational, cognitive, functional, and neuropsychiatric assessments. Although each of these elements is presented separately, they are interrelated and collectively characterize the neurobehavioral function of the patient. The initial contact with the patient affords the opportunity to assess whether a cognitive, attention, or language disorder is present. Questioning of an informant may bring to light changes in cognition, function, and behavior that the patient either is not aware of or denies.

Observation of a patient’s level of arousal or alertness, appearance, emotion, behavior, movements, and speech provides insight into their mental status.

Level of consciousness An accurate assessment of a patient’s mental status and neurologic function must first document the patient’s alertness or level of arousal. Altered levels of consciousness can directly impact the patient’s cognitive performance on mental status testing and influence the examiner’s interpretation of the test results and may be indicative of a medical or neurologic condition requiring immediate medical intervention (eg, cardiopulmonary intervention, neurosurgical evaluation).

Abnormal patterns of arousal include hypoaroused or hyperaroused states. Decreasing levels of arousal include lethargy, obtundation, stupor, and coma. The lethargic patient is drowsy or fatigued and falls asleep if not stimulated, however while being interviewed, the patient will usually be able to attend to questioning. Obtundation refers to a state of moderately reduced alertness with diminished ability to consistently engage the

environment. Even in the presence of the examiner, if not stimulated, the obtunded patient will drift off. The stuporous patient requires vigorous stimulation to be aroused. Responses are usually limited to simple “yes/no” responses or may consist of groans and grimaces. Coma, which represents the end of the continuum of hypoarousal states, is a state of unresponsiveness to the external environment. In older adults, hypoarousal states can be associated with systemic infection, cardiac or pulmonary insufficiencies, meningoencephalitis, increased intracranial pressure, toxic-metabolic insults, traumatic brain injury, seizures, or cerebrovascular disease. Coma requires either bilateral hemispheric dysfunction or brain stem dysfunction. Another important consideration is the role of polypharmacy. Drug interactions are more common in the older adult and can significantly impair consciousness.

Hyperarousal states, on the other hand, are characterized by anxiety, autonomic hyperactivity (tachycardia, tachypnea, and hyperthermia), agitation or aggression, tremor, seizures, or exaggerated startle response. In older adults, hyperarousal states are most often encountered in toxic- metabolic disorders including withdrawal from alcohol, opiates, or sedative- hypnotic agents. Other causes include tumors (both primary and metastatic), viral encephalitis (particularly herpes simplex), cerebrovascular, and hypoxemia. Some patients may experience fluctuating periods of both hypo- and hyperarousal.

Appearance Assessment of a patient’s physical appearance should acknowledge body size and type, apparent age, posture, facial expressions, eye contact, hygiene, dress, and general activity level. A disheveled appearance may indicate dementia, delirium, frontal lobe dysfunction, schizophrenia or severe depression with psychotic features. Wearing excessive makeup or flamboyant grooming or attire in an old individual should raise the suspicion of a manic episode or frontal lobe dysfunction.

Patients with unilateral neglect may fail to dress, groom, or bathe one side of their body. Patients with Parkinson disease may display a flexed posture, whereas patients with progressive supranuclear palsy have an extended, rigid posture. The overall appearance of an individual should also provide information regarding their general health status. The cachectic patient may harbor a systemic illness (eg, cancer) or have anorexia or depression.

Emotional state and affect Affect describes the mental representation of external reality and the patient’s internal feelings about external reality, while emotional state describes the objective display of emotion through facial

grimaces, vocal tone, and body movements, and the subjective component of how the patient reports what he or she feels internally: “I feel sad, happy, apprehensive, cynical.”

Depression is the most frequent mood disturbance in older adults and occurs in a variety of neurologic disorders (Table 9-2). Euphoria or full- blown mania occurs less often than depression in the course of neurologic illness. Euphoria is most common with frontal lobe dysfunction (trauma, frontotemporal degenerations, and infections) and with secondary mania. Anxiety occurs in a variety of neuropsychiatric conditions including anxiety disorders, metabolic encephalopathies (eg, hyperthyroidism, anoxia), toxic disorders (eg, lidocaine toxicity), and degenerative diseases (eg, Alzheimer disease, Parkinson disease). Objective and subjective emotional components may be incongruent in certain psychiatric disorders (eg, schizophrenia and schizotypal personality disorder) and in neurologic conditions such as pseudobulbar palsy.

TABLE 9-2 ¦ POSSIBLE CAUSES OF DEPRESSION IN OLDER ADULTS

The range and intensity of the observable component of emotion should be noted. Constriction or flatness is observed in apathetic states, for example, in the context of negative symptoms of schizophrenia, severe melancholic depression, or in demented patients with apathy. Increased intensity, on the other hand, is seen in mood disorders such as bipolar illness, and in personality disorders such as borderline personality.

Lability is a disorder of emotional regulation. Patients with marked lability are irritable and shift rapidly among anger, depression, and euphoria. The emotional outbursts are usually short-lived. Labile mood is seen in mood disorders such as bipolar illness and in certain personality disorders such as borderline personality. It also may occur in frontotemporal dementia and pseudobulbar palsy.

Behavior Behavioral observations can reveal important information regarding the mental status and neurologic function of the patient. A variety of personality alterations can be encountered with focal brain lesions.

Orbitofrontal dysfunction may be characterized by impulsiveness or undue familiarity with the examiner, lack of judgment or lack of social anxiety, and antisocial behavior. Individuals with dorsolateral frontal lobe dysfunction may be inattentive and distractible. Apathy (lack of motivation, energy, emotional reciprocity, social isolation) may be caused by medial frontal dysfunction. Dementias are associated with increased rigidity of thoughts, egocentricity, diminished emotional responsiveness, and impaired emotional control.

Movement Observation of patient’s movements may provide evidence of parkinsonism, chorea, myoclonus, or tics (Table 9-3). Psychomotor retardation (ie, slowed central processing and movement) may be indicative of vascular dementia, subcortical neurologic disorders, parkinsonism, medial frontal syndromes, or depression. Psychomotor agitation may be indicative of a metabolic disorder, choreoathetosis, seizure disorder, mania, or anxiety.

TABLE 9-3 ¦ COMMON MOVEMENT DISORDERS AND SIGNS

Speech and communication Observation of spontaneous speech is the first step in formal language testing and can be assessed during history taking as well as in the course of the mental status examination. The examiner first observes spontaneity of speech as well as the timber, pitch, and modulation of voice. Mutism may be encountered in several neurologic conditions such as akinetic mutism, vegetative state, locked-in syndrome, catatonic unresponsiveness, or large left hemispheric lesions. Akinetic mutism is characterized by absent speech in the setting of alert-appearing immobility. The patient’s eyes are open, and the individual may follow environmental events. The patient exhibits regular sleep-wake cycles but may be completely inert or display brief movements or postural adjustments spontaneously or in response to vigorous stimulation. Akinetic mutism may be seen with large frontal lobe injuries, bilateral cingulate gyrus damage, or midbrain pathology. Akinetic mutism should be distinguished from a vegetative state where the patient exhibits sleep-wake cycles with open eyes. A vegetative state can occur after severe brain injury. Locked-in syndrome occurs with bilateral pontine lesions, rendering the patient mute and paralyzed. Intellectual function, however, is not impaired and the patients can communicate by eye movements or eye blinks.

Spontaneous speech is characterized by its rate, rhythm, volume, response latency, and inflection. Accelerated speech may be encountered in mania, disinhibited orbitofrontal syndromes or festinating parkinsonian conditions, whereas a reduced rate of speech output can occur as a component of psychomotor retardation. Response latencies may be prolonged or the patient may impulsively interrupt the examiner, anticipating the question. Perturbed speech prosody (loss of melody or inflection) can be encountered in brain disorders affecting the right hemisphere or the basal ganglia. Empty speech with hesitations or circumlocutions can be exhibited in patients with word-finding difficulties. Word-finding impairment may occur in aphasias, metabolic encephalopathies, physical exhaustion, sleep deprivation, anxiety, depression, or dorsolateral frontal lobe damage in the absence of an anomia.

Aphasia is characterized by impairment in oral and/or written communication. Deficits will vary depending on the location and extent of anatomic involvement. Aphasias are generally characterized as nonfluent or fluent (Table 9-4). Nonfluent aphasias are characterized by a paucity of speech, often with a hesitant quality. There is impairment in word searching and writing. The patient may appear frustrated or depressed because of awareness of the language deficit and the inability to communicate with family and health care providers. Fluent aphasias are characterized by empty speech. Word production is normal or may be increased but there is a lack of comprehension about what words mean, often associated with impairment in reading ability. The patient often displays little insight to the language deficit and instead may become agitated because others are not following the conversation.

TABLE 9-4 ¦ CHARACTERISTICS OF APHASIAS

The assessment of cognitive function should be conducted methodically and should assess comprehensively the major domains of neuropsychological function (attention, memory, language, visuospatial skills, executive ability). The patient’s age, handedness, educational level, and sociocultural background may all influence cognitive function and should be determined prior to initiating or interpreting the evaluation.

Attention Two tests are useful in assessing attention: digit span forward and continuous performance tests. In the digit span forward test, the patient is asked to repeat increasingly long series of numbers (eg, 1, 3-7, 4-6-3, 5-1-9- 2, etc). The examiner says the numbers at a rate of one per second. A normal forward digit span is seven digits; fewer than five is abnormal.

Concentration is evaluated by a continuous performance test. An example would be to say the months of the year in reverse order, starting with the last month of the year (December). Distractible patients tend to lose track and skip 1 or 2 months. Serial subtraction can also be used to test concentration but heavily dependent on educational attainment and mathematical abilities. Confusional states such as delirium are characterized by impaired attention.

Memory Learning, recall, recognition, and memory for remote information are assessed in the course of mental status examination. Asking the patient to remember three words and then asking him or her to recall the words 3 minutes later can help assess learning, recall, and recognition. However, the shorter the list, the easier it is to remember, particularly in high-functioning individuals. When told to remember items, patients will often remember the first two items heard (known as “primacy”) and the last two items heard (known as “recency”); therefore, longer lists of 10 words may be preferable. After a delay, recall of fewer than five words is considered abnormal.

Patients having difficulty with recall may be given clues (eg, the category of items to which the word belongs or a list of words containing the target) to distinguish between storage and retrieval deficits. Prompting and clues will not aide patients with storage deficits (eg, amnesia); patients with intact storage but poor recall (eg, retrieval-deficit syndrome) may be aided by clues. Amnestic deficits are thought to be caused by lesions in the hippocampal-thalamic circuit while retrieval deficits are likely due to lesions of frontal-basal ganglia circuitry.

Information is gathered on the patient’s remote memory function while taking a history of the patient’s illness, inquiring about the patient’s life events (marriage, births of children, etc), and asking about important historical events. An informant may also be helpful here to verify these events. The temporal profile of remote memory may be diagnostically important. Amnestic syndromes such as dementias usually feature normal, nonmemory cognitive functions, a period of retrograde amnesia following the onset of the disorder, variable periods of anterograde amnesia, and intact remote memory beyond the period of the retrograde amnesia. Psychogenic memory loss may include variable patterns of amnesia particularly in long- term events (eg, not recall birth of children, not recall being married).

Language Language assessment entails the evaluation of all aspects of communication including spontaneous speech, comprehension, repetition, naming, reading, and writing. Aphasic disturbances are characterized as fluent or nonfluent. Fluent aphasias are characterized by normal or excessive amounts of speech, preserved phrase length, intact speech melody, usually in combination with a paucity of information. Phonemic paraphasias (substitution of one phoneme for another); semantic paraphasias (the replacement of one word with another); or neologistic paraphasias (the

construction of new words) may occur. Wernicke, transcortical sensory, conduction, and anomic aphasias are fluent aphasic syndromes.

Nonfluent aphasias feature reduced verbal output, short or one-word replies, agrammatism, poor speech initiation, reduced speech prosody, and dysarthria. There are few paraphasias. Broca, transcortical motor, global, and mixed transcortical aphasias are nonfluent aphasic disorders.

Interestingly, nonfluent aphasic patients may have preserved abilities to curse fluently and sing well-learned songs (eg, “Happy Birthday”) with few errors.

Primary progressive aphasia is a disorder seen in patients with asymmetric frontotemporal degeneration that involves dominant hemisphere. Progressive nonfluent aphasia involves primarily unilateral left frontal, left frontoparietal, or left frontotemporal degeneration and is characterized by agrammatism, paraphasias, and anomia. Bilateral temporal lobe atrophy and hypoperfusion with more pronounced involvement of the left anterior temporal lobe may cause semantic dementia that is characterized by progressive loss of knowledge about objects, people, facts, and words; it is often accompanied by visual agnosia (inability to name or recognize objects presented visually).

Language comprehension is tested by asking the patient to follow increasingly complex linguistic constructions. The easiest commands are one-step orders such as “stand up” and “turn around,” “open your mouth,” and “stick out your tongue.” Asking the patient to point to room objects or body parts is the next level of comprehension difficulty. Finally, more complex questions, such as “If a lion is killed by a tiger, which animal is dead?” are asked. Impaired comprehension usually implies dysfunction of parietotemporal regions of the left hemisphere. Comprehension is abnormal in most fluent and global aphasic syndrome but may be preserved in nonfluent syndromes. In older adults, it is important to establish that hearing is intact before testing comprehension. Failure to comprehend commands may reflect the inability to hear as opposed to impaired comprehension.

Repetition is assessed by asking the patient to repeat increasingly long phrases or sentences. Generally, it is best to begin with simple phrases such as salutations (“Hello”) and progress to more complex phrases (“Around the rugged rock, the ragged rascal ran”). Omissions and paraphasic substitutions may disrupt accurate repetition. Repetition is impaired in Wernicke, Broca, conductive, and global aphasia but is generally preserved in transcortical aphasias.

Naming tests involve asking the patient to name objects, parts of objects, and colors. Errors include paraphasias, circumlocutory responses, and simply making no response. Aphasic patients may use descriptive terms rather than giving the proper name. For example, a “watch” becomes “the thing you tell time with.” Anomia occurs in aphasia, dementia, delirium, and can sometimes be seen as a consequence of head trauma. Adequate vision and object recognition must be ensured before errors are ascribed to naming deficits.

When assessing reading, the patient’s ability to read aloud and to comprehend what is read must both be tested. Adequate vision must be ensured before failures are ascribed to an alexia. Most aphasias have concomitant alexias, however the converse may not be true. In alexia with agraphia and alexia without agraphia, reading abnormalities may occur in the absence of other signs of aphasia.

Mechanical or aphasic abnormalities may cause agraphia. Micrographia is a characteristic aspect of parkinsonism in which the script becomes progressively smaller as the patient writes a sentence or extended series of numbers or letters, and mechanical agraphias occur in patients with limb paresis, limb apraxia, or movement disorders such as tremor and chorea.

Aphasic agraphias accompany aphasic syndromes and errors similar to those noted in verbal output are present in written form. In Gerstmann syndrome (agraphia, acalculia, right-left disorientation, finger agnosia), alexia with agraphia, and disconnection agraphia (occurring with injury of the corpus callosum), agraphia occurs without aphasia. Agraphia also occurs in dementia and delirium.

Orientation Orientation to time is tested by asking the patient to identify the correct day of the week, date, month, and year. Although some patients may make excuses (eg, they are retired, they don’t need to know, etc.), only correct answers should be counted. This should be followed by asking the patient to guess the correct time of day without looking at a watch or clock. The patient should be within 1 hour of the correct time. Orientation to place is assessed by asking about city, county, state, and current location. If the patient is from out of town, major landmarks may be substituted for less

well-known information such as county. Lastly, orientation to situation can be assessed by asking the patient why they are in the office today.

Abstraction Similarities, differences, idioms, and proverb interpretation can all be used to assess abstracting capacity. These tests are heavily influenced

by culture and educational attainment. Abstraction abnormalities are a nonspecific indicator of cerebral dysfunction. Patients with frontal lobe disorders have disproportionately severe abstracting disturbances.

Judgment and problem-solving abilitie s Assessing judgment assists in exploring the patient’s interpersonal and social insight. Judgment is impaired in many neurologic conditions. Damage to orbitofrontal subcortical circuit (eg, in frontotemporal dementia, trauma, or focal syndromes) produces marked alterations in social judgment. Problem-solving can be assessed by giving a scenario “If in a strange town, how would a person locate a friend they wished to see?” Correct answers might include use of phone book, the Internet, or city directory.

Visuospatial skills There are a number of visuospatial abilities including spatial attention, perception, construction, visuospatial problem-solving, and visuospatial memory. Constructional tasks are most widely used to assess visuospatial ability. In the clock-drawing test, the patient is asked to draw a clock and draw the hands of the clock to indicate a specific time. The hands should be of different lengths. Watching the patient complete the clock is sometimes as informative as the finished product.

Patients with executive dysfunction may draw a clock face that is too small to contain the required numbers (poor planning), whereas patients with unilateral neglect will ignore half of the clock face.

Tests of copying involve having the patient reproduce figures such as a circle, intersecting circle and triangle, overlapping pentagons, cube, or more complex figures. Abnormalities include failures to reproduce the shapes accurately, perseveration on individual elements, drawing over the stimulus figure, or unilateral neglect. Drawing disturbances are common with many types of neurologic conditions including focal brain damage, degenerative disorders, and toxic and metabolic encephalopathies.

Calculation In assessing calculation skills, patients are asked to add or multiply one or two digits mentally or to execute more demanding problems with pencil and paper. Calculation abilities are related to education and occupation. Acalculias may occur in association with a number of aphasic syndromes while visuospatial disorders lead to incorrect alignment of columns of numbers. Primary anarithmetias (inability to do math) are produced by damage to the posterior left hemisphere.

Executive function Executive function is assessed by asking the patient to perform tasks mediated by frontal-subcortical systems. Frontal-subcortical systems are complex neural circuits that include the dorsolateral prefrontal cortex, striatum, globus pallidus/substantia nigra, thalamic nuclei, and connecting white matter tracts. Patients with executive dysfunction manifest perseveration; motor programming abnormalities; reduced word list generation (left dorsolateral dysfunction); reduced nonverbal fluency (right dorsolateral dysfunction); poor set shifting; abnormal recall with intact recognition memory; loss of abstraction abilities; poor judgment; and impaired mental control. These abnormalities are common following head trauma, frontal lobe degenerations, frontal lobe neoplasms, multiple sclerosis, Huntington disease, and other basal ganglia disorders, subcortical infarctions, and in some brain infections such as syphilis.

Digit span backward is a test of mental control and complex attention, as well as executive dysfunction. It entails saying increasingly long series of numbers and asking the patient to say them backward (give 2-5-8, response should be 8-5-2). A normal digit span in reverse is five digits; fewer than three is abnormal.

Word list generation Word list generation is a very useful test and involves asking the patient to think of as many members of a specific category (most commonly animals) as possible within 1 minute. Normal individuals can name approximately 18 animals within 1 minute; fewer than 14 is considered abnormal. Word list generation deficits occur with anomia, frontal- subcortical systems dysfunction, and psychomotor retardation. It is a highly sensitive test but lacks specificity.

Informant assessment In many instances, asking questions of the informant will provide a wealth of information regarding the baseline abilities of the patient. There are several structured interviews that are short, easy to administer, and do not require specific training. Functional abilities and activities of daily living can be assessed with the Functional Activities Questionnaire, the Physical Self-Maintenance Scale, Instrumental Activities of Daily Living Scale, or the Barthel index. Baseline cognitive abilities can be assessed with brief informant interviews such as the Quick Dementia Rating System (QDRS), AD8, or the IQCODE. The AD8 was developed in a research sample and validated in a clinic population and asks eight questions regarding change in the patients’ memory, orientation, judgment and problem- solving abilities, executive function, and interest level. Endorsement of two

or more items suggests cognitive dysfunction and should trigger a more formal evaluation.

The neuropsychiatric interview of the patient includes the evaluation of thought form, thought content, and insight. The new onset of disturbances in any of these domains in older patients is unusual in the absence of a brain disease. Their emergence should trigger the search for a neurologic or psychiatric condition.

Thought form Formal thought disorders such as tangentiality, circumstantiality, loose associations, illogicality, derailment, and thought blocking are much less common than disturbances of thought content as a manifestation of psychosis in neurologic diseases. Thought disorders have been observed in the psychoses accompanying epilepsy, Huntington disease, and idiopathic basal ganglia calcification.

Perseveration and incoherence are disorders of the form of thought that are common in neuropsychiatric conditions. Perseveration refers to the inappropriate continuation of an act or thought after conclusion of its proper context. Intrusions are a special case of perseveration with late recurrences of words or thoughts from an earlier context. Perseverations and intrusions are seen in aphasias and dementing illnesses. Incoherence refers to the absence of logical association between words or ideas. It is observed in delirium, advanced dementias, and as part of the output of fluent aphasia.

Thought content Several types of disorders of thought content occur in neurologic diseases. Delusions are the most common manifestation of psychosis in neurologic disorders and are characterized by false beliefs based on incorrect inference about external reality. Common types of delusions encountered involve being followed or spied on, theft of personal property, spousal infidelity, or the presence of unwelcome strangers in one’s home. Theme-specific delusions such as the Capgras syndrome (the belief that someone has been replaced by an identical-appearing impostor) may also be observed in neurologic illnesses. Delusions are common in a number of dementia etiologies including Alzheimer disease and dementia with Lewy bodies, and may occur in vascular dementia, frontotemporal dementia, and Huntington disease.

Hallucinations occur in many neurologic disorders. Hallucinations are sensory perceptions that occur without stimulation of the relevant sensory

organ. Hallucinations and delusions occur together in psychosis; hallucinations are nondelusional when the patient recognizes the sensory experience to be unreal. Hallucinations may involve any sensory modality (visual, auditory, tactile, gustatory, olfactory) and may be formed (eg, people or things) or unformed (flashing lights or colors). Hallucinations occur with ocular and structural brain disorders as well as Charles Bonnet syndrome, epilepsy, narcolepsy, and migraine. Well-formed visual hallucinations (children, furry animals) are a prominent early sign in dementia with Lewy bodies. Less well-formed visual hallucinations occur in the moderate to severe stages of Alzheimer disease. Gustatory or olfactory hallucinations are most common in seizure disorders, bipolar disorder, and schizophrenia, and with tumors located in the medial temporal lobe. Tactile hallucinations are most commonly associated with schizophrenia, affective disorders, or drug intoxication or withdrawal.

Insight Patients with neuropsychiatric disease may display limited insight and be unaware of their medical conditions or limitations in function; thus assessment of a patient’s insight into the severity of their illness can yield useful diagnostic information and assist in developing a therapeutic plan. For example, Alzheimer disease patients have impaired insight into their memory and cognitive difficulties, whereas patients with vascular dementia and dementia with Lewy bodies often exhibit more appropriate concern regarding their cognitive dysfunction. Lesions of the right parietal lobe are associated with unawareness, neglect, or denial of the abnormalities of the contralateral side.

Behavior and personality A variety of changes in personality and behavior have been described in neuropsychiatric disease in the older adult. Personality changes may include increased egocentricity and thought rigidity, impaired emotional control and diminished emotional responsiveness, loss of interest and apathy, and lack of concern for the feelings of others. No brief personality rating scales are available but in the proper setting the Neuroticism-Extroversion-Openness Five-Factor Inventory (NEO-FFI) can be used to evaluate personality. Behavioral changes including irritability, depression, anxiety, hallucinations, delusions, and vegetative changes can be assessed with the Neuropsychiatric Inventory (NPI). Both long and short forms of the NPI are available.

The neurologic examination includes assessment of cranial nerve function, strength, coordination, sensation, muscle stretch reflexes, pathologic/primitive reflexes, and neurovascular status. Examination of head and neck may provide additional important information.

Cranial nerve I: olfactory In normal aging, loss of olfaction may be a nonspecific or clinically insignificant finding. Olfaction may be impaired following head trauma, infection, zinc deficiency, vitamin A deficiency, frontal lobe dysfunction, vitamin B12 deficiency, and frontal lobe tumors (olfactory

groove meningioma). Olfaction is tested by asking the patient to identify a variety of odors. When testing, it is important to use simple and familiar odors (coffee beans, vanilla, or cinnamon). Complex scents such as perfumes and noxious agents (ie, ammonia) should not be used. Ideally, the patient should close their eyes and each nostril should be tested separately.

Cranial nerve II: optic Examination of the optic nerve includes visual inspection of the nerve head, testing of visual acuity, and mapping of the visual fields. In aging, visual acuity may be impaired and can be due to a number of neurologic and ophthalmologic causes. First, casual inspection of the corneal, sclera, and mucosal tissue should be carried out to evaluate structural abnormalities. Visual acuity can be evaluated with a Snellen visual chart or Rosenberg card held 14 in from the eye. Screening should be done in a well-lit environment and to the patient’s advantage allowing them to use their corrective lenses. If they do not have their glasses with them, refractive errors can be partly corrected by using a pinhole. Visual fields are tested at the bedside by confrontation. The examiner should face the patient, sitting or standing at a similar height and each eye should be tested independently. The patient is asked to look at the examiner’s nose and the examiner’s arms are extended laterally. The patient is asked to differentiate between one or two fingers. Each quadrant should be tested separately. After testing each eye individually, both eyes should be tested simultaneously for visual neglect.

Monocular visual field deficits can be associated with glaucoma. Abrupt changes in visual fields or acuity should alert the clinician to potential vascular etiologies. Homonymous field deficits reflect disruption of the optic pathway posterior to the optic chiasm.

Pupillary examination should include evaluation of size and shape. Up to a 1-mm difference in size is generally considered normal. Pupillary responses are tested with a bright flashlight (not the ophthalmoscope). A normal pupil reacts to light by constricting; the contralateral pupil should also constrict. The pupils also constrict when shifting focus from a distant object to a near object (accommodation) and during convergence such as when patients are asked to look at their nose. Abnormalities of pupillary responses are associated with a number of neurologic disorders (Table 9-5). A review of medications is also important as a number of drugs can affect pupillary size. Mydriasis (pupillary dilation) can be caused by atropine-like drugs, while miosis (pupillary constriction) can be caused by parasympathomimetic drugs.

TABLE 9-5 ¦ CAUSES OF PUPILLARY CHANGES IN OLDER ADULT

A careful examination of the optic nerve should be performed in all patients. It is not always necessary to do a dilated examination, but the room should be darkened to increase pupillary size. The sharpness of optic disc margins, the ratio of optic cup to disc, venous pulsations, the caliber of blood vessels, and the presence of exudates, hemorrhages, emboli, and retinal pallor should be noted. Papilledema is characterized by blurring or elevation of the disc margins with the loss of normal venous pulsations and reflects raised intracranial pressure. As pressure increases, hemorrhages may be found adjacent to the disc. Glaucoma increases the size of the optic cup relative to the disc.

Cranial nerves III, IV, and VI: oculomotor, trochlear, and abducens The oculomotor, trochlear, and abducens nerves mediate ocular motility, pupillary responses, and eyelid position. The trochlear nerve innervates the superior oblique muscle, the abducens nerve innervates the lateral rectus muscle, while the oculomotor nerve innervates the remainder of the extraocular muscles. The oculomotor nerve also innervates the levator muscles of the eyelid and carries parasympathetic nerves to the pupil. Testing each eye individually helps to identify ocular motility dysfunction. In aging, ocular motility may be reduced. Normal older adults can exhibit restricted convergence and limitation of conjugate upward gaze. Other nonspecific concomitants of normal aging include the evolution of small sluggishly reactive pupils, loss of Bell phenomenon (upward eye deviation on eye closure), and the inability to dissociate ocular movements from head movements. The clinician should be concerned when an older patient exhibits new-onset diplopia, pupillary asymmetry, nystagmus (Table 9-6), or extraocular movement disorders.

Ptosis (drooping of the upper lid) can be caused by a number of disorders (Table 9-7). Isolated abducens palsies may be a sign of elevated intracranial pressure since the sixth nerve has the longest intracranial course.

TABLE 9-6 ¦ TYPES OF NYSTAGMUS AND OCULAR OSCILLATIONS

Cranial nerve V: trigeminal The trigeminal nerve is divided into three divisions: ophthalmic, maxillary, and mandibular. The first two divisions are pure sensory nerves mediating facial and corneal sensation. The third division carries both sensory fibers and innervates the muscles of mastication. The corneal reflex is mediated by the ophthalmic division and can be tested by lightly stimulating the cornea with a wisp of cotton. When the cornea on one side is stimulated, both eyes should close. Facial sensation is tested with a safety pin or cold handle of a tuning fork. Motor function is tested by asking the patient to bite down or open the jaw against resistance. Tumors of the middle fossa and in the cerebellopontine angle may compress the fifth cranial nerve and produce a cranial nerve syndrome with decreased corneal reflex and sensory loss on the ipsilateral face. Tic douloureux (trigeminal neuralgia) is a paroxysmal pain disorder triggered by touching sensitive zones usually within the mandibular division. The cause may be idiopathic, due to compressive lesions or demyelination at the root entry zone.

Cranial nerve VII: facial The facial nerve supplies the facial musculature, lacrimal and salivary glands, and taste fibers of the anterior tongue. The motor function is tested by asking the patient to wrinkle their forehead, close their eyes, and smile. Unilateral weakness may cause a flattening of the nasolabial fold. If very weak, the patient may experience drooling. The eyelid is usually not severely affected with central lesions and the upper forehead is spared. In peripheral lesions such as Bell palsy (Table 9-8), patients are unable to close their eye or wrinkle their forehead. The facial nerve also innervates the stapedius muscle of the middle ear which helps to modulate tympanic membrane vibration. This motor branch can be damaged during closed head trauma leading to hyperacusis, an increased perception of sound. The sense of taste is not often tested, but can be done at the bedside using sugar, salt, or lemon juice. The patient is asked to stick their tongue out and a small amount of solution is placed on one side of the tongue. The patient is asked to describe the taste, and then allowed to drink some water before the next solution is applied.

TABLE 9-8 ¦ CAUSES OF BELL PALSY

Cranial nerve VIII: cochlear and vestibular Hearing and vestibular function are mediated by the eighth cranial nerve. Evaluation of hearing at the bedside is sometimes difficult. Use of a 512-Hz tuning fork can help discriminate conduction from sensorineural hearing loss. The Rinne test is done by placing a vibrating tuning fork on the mastoid process. As soon as the patient is unable to detect sound, the tuning fork is moved to a position near the external auditory canal. If the patient has normal hearing, air conduction should be better than bone conduction. If the patient has conduction deafness, the sound will not be heard because of pathology in the middle ear. In nerve deafness, air conduction is better than bone conduction, but both will be reduced. The Weber test looks for lateralization. The tuning fork is placed in the middle of the skull and the patient is asked to decide where they best hear the sound. In normal hearing, the sound is heard equally in both ears. In conduction deafness, vibrations are best heard in the abnormal ear. In nerve deafness, the sound is best appreciated in the normal ear. Decreased hearing for high-pitched sounds and lack of perception of background noise are common findings in normal aging and by themselves should not be considered a pathologic finding. Sensorineural deafness is characterized by loss of high-pitched sounds while conduction deafness is characterized by loss of low-pitched sounds. Tinnitus or ringing in the ears is a common symptom in adults. Tonal tinnitus is subjective and heard only by the patient. Nontonal tinnitus is more objective because in certain circumstances, the

tinnitus can be heard by the examiner. The differential diagnosis of tinnitus is presented in Table 9-9.

TABLE 9-9 ¦ DIFFERENTIAL DIAGNOSIS OF TINNITUS

Vestibular lesions produce nystagmus and vertigo. Vestibular nystagmus is horizontal or combined horizontal-rotatory and is typically accompanied by vertigo and nausea, whereas lesions disrupting vestibular connections in the central nervous system can produce nystagmus in any direction but are usually not associated with vertiginous or nauseous sensations. When characterizing nystagmus, only the fast component should be described. The complaint of dizziness in older adults is not uncommon; however, the examiner must determine whether the dizzy patient is experiencing light- headedness or true vertigo. If true vertigo is present, then the clinician should further discern whether it is peripheral (vestibular) or central (brain stem) in origin as well as associated features (Table 9-10). Causes of vertigo associated with vestibular disease include benign positional vertigo, Meniere syndrome, and trauma.

TABLE 9-10 ¦ CAUSES OF VERTIGO AND ASSOCIATED FINDINGS

Cranial nerves IX and X: glossopharyngeal and vagus The ninth and tenth cranial nerves control pharyngeal and laryngeal function, taste, and the gag reflex. Glossopharyngeal lesions cause asymmetric elevation of the palate and deviation of the uvula. Hoarseness, aphonia, and dysphagia occur with vagus nerve lesions. In normal aging, the gag reflex can be reduced and, when accompanied by a decrease in the cough reflex, can result in difficulty handling bronchial secretions. Glossopharyngeal neuralgia is a rare paroxysmal pain syndrome involving the posterior pharynx or tonsils usually triggered by excessively hot or cold foods or liquids.

Cranial nerve XI: accessory nerve The spinal accessory nerve innervates the upper half of the trapezius and the sternocleidomastoid muscle. In normal older adults, frank weakness of the trapezius or sternocleidomastoid muscle is not a typical finding and, if present, should be investigated further. A delayed shrug may be an indication of a mild ipsilateral hemiparesis.

Cranial nerve XII: hypoglossal The hypoglossal nerve innervates the tongue. Patients are asked to stick their tongue out; deviation to either side implies a lesion on the side of deviation. The tongue should also be examined for atrophy and spontaneous muscle contractions (fasciculation) suggesting upper

motor neuron disease. Fasciculation is best detected on the lateral aspects of the tongue. Tongue weakness is also common in pseudobulbar palsy.

Muscle bulk, strength, tone, and coordination are assessed as part of the motor system examination.

Muscle bulk Muscle bulk is examined by visual inspection and palpation. Muscle wasting may occur with disuse; muscle, nerve, or spinal disease; and in generalized weight loss secondary to malnutrition, systemic illness, or advanced brain diseases. Mild muscular wasting without associated weakness can be encountered in normal aging most commonly involving the intrinsic hand and foot muscles, calf, and shoulder girdle muscles.

Muscle tone Muscle tone may be increased or decreased in neurologic disorders. Muscle tone is decreased in muscle and peripheral nerve disease, with cerebellar disorders, early in the course of many choreiform disorders, and acutely following an upper motor neuron lesion. Increased muscle tone is encountered in spasticity with pyramidal tract lesions and rigidity with extrapyramidal disorders. Cogwheel rigidity of Parkinson disease is best palpated when manipulating the distal limbs, usually in a circular motion. “Gegenhalten” refers to the active resistance to movement encountered in advanced brain diseases. In order to optimize the diagnostic yield of the muscular tone examination, the clinician should distract the patient while the examination is performed. For example, the clinician could ask the patient to perform circulatory movements with the right hand as if he “is washing a window” while he is examining the muscular tone on the left arm. By this means, a more accurate representation of the tone is obtained. This is particularly useful in patients with Parkinson disease, when the examiner is testing for cogwheel rigidity. Since rigidity is recognized as one of the cardinal motor symptoms in Parkinson disease, performing an optimal muscular tone examination increases the diagnostic yield of this disease.

Strength Strength is graded as 0 (no evidence of muscle contraction), 1 (muscle contraction without movement of the limb), 2 (limb movement after gravity eliminated), 3 (limb movement against gravity), 4 (limb movement against partial resistance), or 5 (normal strength). Distal weakness is most indicative of peripheral neuropathies, whereas proximal weakness is more consistent with primary muscle disease. In aging, mild generalized weakness

may occur; however, focal weakness is indicative of a neuropathologic process. Focal weakness often is subtle and may be detected only with careful examination. Hemiparesis occurs with lesions of the pyramidal system. When testing strength, the examiner should attempt to isolate individual muscles (thumb abduction) rather than testing whole groups (hand grip) to detect subtle signs of weakness. A pronator drift is seen with mild forms of weakness. When testing for muscular strength, the examiner should be familiarized with functional motor weakness. Known as the “Hoover test”, this sign is the most useful to examine for functional weakness. When performing this test, the clinician should ask the patient to raise the affected leg without resistance. If a discrepancy is observed between voluntary hip extension (which is weak) and involuntary hip extension when the opposite hip is being flexed against resistance (which is normal), this finding would point toward a diagnosis of functional weakness.

Abnormal movements During the interview and examination, the clinician should be observant for any movement that is not purposeful including tremor, chorea, dyskinesias, and ballismus. Tremor is usually described as action (associated with a movement) or rest (disappears with movement of affected extremities). “Essential” tremor is a usually benign hereditary condition associated with movement or sustained posture and may involve arms, legs, head, chin, or voice. Essential tremors often improve after drinking small amounts of alcohol.

Primary modalities, including light touch and temperature are tested to assess sensory function. Sensory examination is quite subjective, and it is important to consider the consistency of responses and how sensory complaints relate to other signs and symptoms. Peripheral causes of sensory loss typically present bilaterally and are largely symmetric. Unilateral sensory loss occurs with lesions of primary sensory cortex or its projections.

Light touch Evaluation of light touch is not particularly helpful in discriminating pathology but is useful in defining the presence or loss of sensation. Lightly stroking the fingers or a wisp of cotton across the skin may help elicit dermatomal patterns of sensory loss for further evaluation.

Pain and temperature Pain and temperature sensation is carried by small unmyelinated fibers. Pain can be assessed with the use of a disposable safety

pin while temperature can be assessed with the handle of the reflex hammer or tuning fork. The loss of pain sensation due to a metabolic or toxic peripheral neuropathy typically follows a stocking glove pattern, while lesions due to a radiculopathy follow a defined dermatome.

Vibration Vibration is carried by large, myelinated fibers and is assessed with a 128-Hz tuning fork. The tuning fork should be struck and placed on a bony prominence. Causes of pathologic decreased vibratory sensation include peripheral neuropathies, diabetes, tabes dorsalis, vitamin B12 deficiency, and

Position Proprioception is assessed by having the patient close their eyes and the examiner gently moves toes or fingers in the vertical plane. Skin proprioception can be assessed by lightly stroking the skin in an up or down fashion. The Romberg sign is performed to assess the integrity of the dorsal columns. The patient is asked to stand with their feet together and eyes closed. The presence of a sway suggests a positive test. If the problem is due to a proprioceptive deficit, the patient is able to correct themselves with their eyes open. Position sense loss can be caused by peripheral neuropathies, diabetes, tabes dorsalis, vitamin B12 deficiency, and

Cerebellar function and coordination may be disrupted by many types of motor and sensory abnormalities. Tests of coordination include rapid alternating movements, fine finger movements, finger-to-nose movements, and heel-knee-shin maneuvers. During aging, there is an overall decrease in speed of coordinated movements that is of no pathologic consequence.

However, gross abnormalities in cerebellar function are not anticipated and should be evaluated thoroughly (Table 9-11).

TABLE 9-11 ¦ ELEMENTS OF ATAXIA AND CEREBELLAR DYSFUNCTION

When unilateral cerebellar dysfunction is present, patient will overshoot target but may improve after a few trials. Dysdiadochokinesis occurs when the patient is asked to rapidly change hand or finger movements; difficulties in maintaining smooth movements are characteristic. Cerebellar lesions can also affect muscle tone causing hypotonia. Cerebellar tremors tend to be coarse and irregular, worsening in the terminal one-third of a movement.

Gate and posture depend on motor, sensory, and cerebellar function. In normal aging, posture becomes more flexed, slowed, and may have a slightly unsteady quality. When assessing gait in the older adult, it is important to recognize gait abnormalities that may be secondary to joint pain and arthritic conditions. Gait is assessed by having the patient walk straight for at least 10 yd, making a turn, and maneuvering in a tight corridor. It is important to note the presence of arm swing and the distance of the stride. The patient should also be asked to tandem walk, walk on their toes and heels and if possible, walk up a few steps. Postural stability is assessed by asking the patient to stand with their shoulder-width apart. A forceful pull is given to their shoulders and the righting response is assessed. The clinician should be prepared to catch the patient. One or two steps of retropulsion are considered normal. Table 9-12 lists common causes of gait disturbance in the older adult.

TABLE 9-12 ¦ GAIT ABNORMALITIES IN THE OLDER ADULT

Decreased muscle stretch reflexes are found in muscle, peripheral nerve, and nerve root disorders, while increased reflexes occur with upper motor neuron lesions. Lateralized hyperactive reflexes in conjunction with spasticity and the Babinski sign are indicative of a contralateral lesion of the pyramidal system. In aging, deep tendon reflexes tend to become hypoactive. Ankle reflexes may be absent in normal aging, but knee reflexes persist.

Reflexes are initially hyperactive in cervical and lumbar spondylosis; however, in advanced cases, absent or diminished reflexes may be found as nerve roots become compromised.

The Babinski sign is dorsiflexion of the great toe with plantar stimulation. It is produced by upper motor neuron lesions. The grasp reflex (involuntary gripping of objects in or near the patient’s hand) occurs in patients with advanced brain disease and with lesions restricted to the medial frontal lobes. The sucking reflex (sucking movements of the lips, tongue, and jaw elicited by stimulation of the lips) occurs in patients with frontal lobe and diffuse brain dysfunction.

The palmomental reflex (ipsilateral contraction of the mentalis muscle in response to stroking of the thenar eminence of the hand) can be seen in normal-aged individuals and may be regarded as pathologic when it is unilateral or when it does not fatigue with repeated palmar stimulation. The glabellar reflex (Myerson sign) is elicited by tapping the patient between the eyes. After a few blinks the patient should suppress further blinking. Patients

with Parkinson disease and other basal ganglia disorders will continue to blink.

Cortical sensory modalities, including two-point discrimination, graphesthesia, and stereognosis should be assessed. Two-point discrimination is best performed with calipers. Graphesthesia is performed with the patient’s eyes closed and numbers are traced onto the palm with the back of the reflex hammer. Stereognosis is also performed with the patient’s eyes closed. Common objects are placed into the patients’ hand and they are allowed to move them about without using the other hand. Deficits imply dysfunction in the contralateral parietal lobe. Cortical sensory function should be assessed independently for each upper extremity. It is important to first assess primary sensory modalities. In the presence of prominent sensory loss, cortical sensory function cannot be assessed.

Examination of the vascular system, including auscultation for cranial and carotid bruits, palpation of peripheral pulses, and assessment of blood pressure (lying, sitting, and standing), complements the neurologic examination and should be performed on every patient.

A variety of neurologic disorders (eg, stroke, Parkinson disease, Alzheimer disease) preferentially present in older adults. A comprehensive mental status and neurologic examination should be performed in every patient to document changes in neurologic function (ie, memory/cognition, behavior/personality, cranial nerves, motor function, and sensory perception) associated with pathologic conditions that affect the nervous system and distinguish them from the functional changes associated with normal aging.

Limited memory and cognitive function changes occur as one age. Subtle changes in memory that do not interfere with normal functioning in society and that do not impair activities of daily living occur in normal aging. More significant declines in memory and cognitive function can be encountered in dementia (Table 9-13).

Altered cognitive function in the setting of a clear sensorium is consistent with dementia secondary to a neurodegenerative process or medical illness. Dementias (eg, Alzheimer disease, frontotemporal dementias, dementia with Lewy bodies) are characterized by a specific constellation of signs and symptoms. In Alzheimer disease the individual typically exhibits limited insight into their cognitive deficits that involve memory, language, and visuospatial skills. Patients with frontotemporal dementias present with a predominance of features consistent with frontal and/or temporal degeneration. These individuals exhibit early changes in behavior and personality, such as social inappropriateness, disinhibition, apathy, perseveration, and oral/dietary changes. Other accompanying features may include language/speech impairment, executive dysfunction, and preserved posterior functions (eg, visuospatial ability, calculations). In dementia with Lewy bodies, patients may exhibit fluctuating cognition, recurrent well-

formed and detailed visual hallucinations, and extrapyramidal signs consistent with parkinsonism. Dementia can occur as a consequence of other neurologic and medical illnesses such as cerebrovascular disease, vitamin B12 deficiency, hypothyroidism, Parkinson disease, and meningoencephalitis.

Delirium on the other hand causes alteration in sensorium and level of consciousness and is usually due to medications (Table 9-14), infection, head injury, or metabolic derangements. Associated features include disruption of sleep-wake cycle, intermittent drowsiness and agitation, restlessness, emotional lability, and frank psychosis (hallucination, illusions, delusions). Symptoms of delirium are often worse at night and occur in up to 20% of hospitalized patients. The risk increases in the older adult and the longer the hospital stay. Predisposing factors include advanced age, dementia, impaired physical or mental health, sensory deprivation (poor vision or hearing), and placement in intensive care units.

TABLE 9-14 ¦ EXAMPLES OF MEDICATIONS CAUSING DELIRIUM IN THE OLDER ADULT

A functional decline in some aspects of cranial nerve function (eg, vision, hearing, vestibular function, taste, and smell) can be anticipated in normal aging and should be distinguished from pathologic conditions afflicting the nervous system. Similarly, older individuals experience decreased mobility as they age. Subtle changes in gait, posture, coordination, and strength are expected concomitants of aging. However, more profound changes that significantly alter mobility and/or present as focal weakness or impaired coordination should alert the clinician to the possibility of a neuropathologic disorder.

Alterations in sensory perception can be indicative of neuropsychiatric dysfunction. Subtle deficits in vibration and other primary sensory modalities may be encountered in normal aging. However, marked deficits in sensory function are suggestive of neurologic disease and require further diagnostic testing.

In conclusion, neurologic findings of normal aging include subtle declines in cognitive function, mildly impaired motor function, and altered sensory perceptions. However, exaggerated impairments in cognitive, behavioral, motor, and sensory function suggest the onset of neurologic

diseases that commonly afflict the older adult. A comprehensive mental status and neurologic examination is the foundation for identifying neuropathologic conditions that necessitate further laboratory and imaging investigation.

This chapter was supported by grants from the National Institute on Aging (R01 AG071514, R01 NS101483, and R01 AG069765), the Anne and Leo

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Karantzoulis S, Galvin JE. Distinguishing Alzheimer’s disease from other major forms of dementia. Expert Rev Neurother. 2011;11:1579–1591. Massano J, Bhatia KP. Clinical approach to Parkinson’s disease: features, diagnosis, and principles of management. Cold Spring Harb Perspect

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All clinicians should be sufficiently familiar with the principles and processes to manage common situations requiring a judgement of decisional capacity that arise in their practice. The purpose of this chapter is to explain some of the ethical underpinnings to this responsibility, to highlight the strengths and weaknesses of approaches to assess decisional capacity, and to describe the role of the clinician in decision making.

Respect for individual autonomy is understood to be an elemental principle of western society. Nonetheless, there are limitations on how autonomous each of us is, including, but not limited to, limitation of resources and opportunity, societal and legal prohibitions, and the limits imposed by the rights of others not to have their autonomy infringed upon. We are not just independent rational creatures devoid of context; decision making encompasses emotion, relationships (individual and community), as well as other enriched interpretations of autonomy that will be discussed further in this chapter.

Paternalism is defined as limiting an individual’s autonomy in order either to prevent that individual from doing harm to themselves (or others) or to prevent the person from missing a substantial benefit. The circumstances under which paternalism is acceptable are not defined by the action the individual may wish to undertake, or by the probable untoward consequences of an action, but rather by the individual’s ability to make decisions. In other

words, our wish to protect an individual from doing themselves harm does not justify paternalism; we cannot prevent an individual from doing things that may cause them harm (ie, drinking alcohol in excess, hang gliding). We can only justify intervention if we judge that an individual lacks the capacity to make decisions. In such a case, we are responsible for protecting the person and society from the possible harm of a decision made by an individual who lacks the ability to understand the consequences.

This chapter will focus on those individuals who have cognitive impairment or a clouded sensorium (fixed brain lesions, dementia, or delirium) and will not discuss the competence of individuals whose decisional capacity may be impaired by psychiatric illness. When patients are cognitively impaired, clinicians have an obligation to respect their rights, to protect their persons, and to consider the safety of the public. This often requires careful balancing of conflicting imperatives.

In the broadest sense of the word, for an individual to be competent, that individual must be well qualified to do whatever task they are doing. For decision making, competence is often viewed as a legal term, that is, a judge’s ruling as to whether an individual has been deemed competent to make their own decisions. An individual adjudicated to be incompetent must have a guardian appointed to make the decisions for the area (or areas) in which the person has been found to be incompetent. Although guidelines vary from state to state, it is generally accepted that a ruling of incompetence cannot be made solely on the basis of a medical diagnosis, age, level of education, or personal eccentricity. An adjudication of competence or incompetence is based on an assessment of the individual’s decisional capacity and that individual’s demonstrated ability or inability to carry out a plan. Therefore, the assessment of decisional capacity should include not just the patient’s cognitive ability, but other factors that may be influencing the process of making a capable decision.

The four elements of making a capable decision are understanding, appreciation, reasoning, and expressing a choice (Table 10-1). First, the individual must be able to comprehend the information being considered sufficiently well to understand the relevant facts. That information must have been presented in a clear and concise manner with special attention taken to ensure that barriers such as hearing impairment, illiteracy, or language difference do not constitute the sole reasons that the person is unable to understand the information. Other issues, such as aphasia, delirium, or depression, may also interfere with the individual’s ability to comprehend and retain information.

TABLE 10-1 ¦ FOUR ELEMENTS THAT CONSTITUTE DECISION-MAKING ABILITIES

Second, the individual must have the conceptual ability to appreciate the consequences of the decision that he or she is making. This includes both an appreciation of the risks and benefits of options and the ability to identify the consequences the decision will have on his or her life. Beginning and ending a discussion by asking the individual what their understanding of the situation is and what the consequences are of the choice that they have made is an important method of assuring that they were able to comprehend the information and that they appreciate the consequences of the decision they are making.

Individuals must be able to reason, within their own frame of reference, why they are choosing a course of action. This is different from saying that a decision seems “reasonable” or “rational,” but rather it refers to the cognitive processing of values and beliefs in view of the information provided. Even if we feel—and even if most of society would feel—that an individual’s decision is irrational, it does not give us grounds to negate the

person’s right to self-determination. Nonetheless, an individual’s ability to give a plausible rationale for his or her decision is sometimes used as secondary evidence of decisional capacity. That is, demonstrating justification for one’s choices (eg, religious belief, personal value, etc.) provides another level of assurance that the patient’s decision rests on intact reasoning, rather than a set of delusional or incoherent beliefs that may exist in the setting of cognitive impairment or psychiatric illness.

Finally, the person must be able to make a choice and communicate the decision. This is the lowest bar for decision-making capacity but one that may be impaired by specific damage in language or frontal lobe function as well as in severe global cognitive impairment.

The inconsistency of an individual’s decision with past decisions made by that person provides a red flag to possible underlying cognitive or psychiatric problems that deserve exploration. But, in and of itself, inconsistency does not negate the person’s right to make decisions.

Inconsistency of a specific decision over time may indicate that the individual has had difficulty with remembering or understanding the information provided.

Individuals may choose to forego making their own decision and delegate that responsibility to someone else even though they retain decisional capacity (waiver of informed consent). Their wish to forego hearing medical information or participating in making a choice (the right to delegate informed consent) may rest on individual, family, societal or cultural difference in decision making.

In protecting an individual who is incapable of making decisions, one action that may become necessary is the application to a local probate court to ask that the individual be adjudicated to be incompetent and to have someone else appointed to make decisions. Although specifics of probate statutes vary among states, most follow a general pattern articulated in the Uniform Probate Code. Once an individual has been adjudicated incompetent, another person is appointed to represent his or her interests. This person is variably referred to as a guardian, conservator, or legal surrogate. Although there are movements toward “limited guardianship” that restrict the powers of the

guardian to decision making in more specific areas where a person has been shown to be incapable, there are two broad categories of guardianship that are commonly used, those of finance and of person. Guardianship of finance is a self-evident term. Guardianship of person grants a more global responsibility for assuring that the individual is kept safe and that decisions are made either as substituted judgment or based on the individual’s best interests (see Chapter 72). These decisions may involve medical care, where a person will live or what help the person will receive to maintain himself or herself.

It should be emphasized that not all incapacitated individuals need to be conserved. There are no statistics available to say how many incapacitated individuals have informal care management by relatives and never require probate action. Personal experience would lead us to believe that most adults with cognitive deficits fall into this category. Probate adjudication of a conservator may not be needed if financial management has been allocated to a family member by a Power of Attorney (POA) prior to the individual becoming incapacitated, and if there is a general agreement among concerned and interested parties that decisions should be made either by a specific individual or group consensus. If the individual involved has granted someone a durable POA for health affairs (see Chapter 26), there may not be a need for court action.

Even when the court has been asked to act, 75% to 85% of the time the court appoints a family member as conservator. The ability of an appointed conservator to act as an appropriate surrogate varies considerably. One advantage of having a court-appointed conservator is that the probate court has some oversight responsibilities for the management of the individual’s affairs. If the need for complex medical decision making does not arise, then the ability of an individual to make those types of decisions is not questioned. If the individual is in a situation where others are managing household affairs and looking out for the person’s needs, then the person’s ability to care for self may not be examined. It is only when a problem arises that the individual’s ability to make these types of decisions becomes an issue.

The clinician’s assessment of an individual’s ability to make decisions is conducted in two different ways; specific testing can measure cognitive

dysfunction and observing the person’s decision-making process can demonstrate his or her inability to complete the decision-making task capably. The clinician needs to first understand the cognitive processes involved in decisional capacity. These processes can be understood both as discrete neuropsychiatric functions and as contributors to the holistic process of making decisions.

Cortical functions involved in decision making include immediate memory and language. Immediate memory is defined as the ability to remember rehearsed or consolidated materials. Language abilities are those that affect comprehension and the ability to produce the intended words when expressing one’s thoughts in both spoken and written communication. The ability to understand language is highly correlated with an individual’s ability to comprehend the information needed to make a decision. Problems with expressive language ability from cortical lesions can lead to statements by the individual that misrepresent his or her thoughts (ie, through misuse of words, word substitutions, or paraphasic errors).

Frontal lobe functions involved in the process of making capable decisions include the abilities to concentrate, express oneself, use abstract reasoning, initiate actions, solve problems, monitor one’s behavior, and use judgment. The frontal lobe is responsible for filtering out both internal and external stimuli that interfere with the individual’s ability to concentrate and to understand instructions or explanations. It helps the individual organize information, apply it to themselves and initiate action as well as to self- monitor. Frontal lobe problems can interfere with all four steps in decision making; understanding, applying reasoning, and the ability to make a decision.

Tools commonly used for the assessment of cognition in patients serve as important triggers to further investigation of the individual’s decisional capacity, but no single cut off score can determine capacity. Looking at performance on individual items and extrapolating to predict how performance will affect the processes necessary for decision making helps the clinician to evaluate a patient. Looking at individual items on these tests and having knowledge of how the cognitive function tested may influence the individual’s ability to make decisions is useful. We recommend tests that look at cortical and frontal lobe function, such as the St Louis University

Mental Status (SLUMS) or the Montreal Cognitive Assessment (MoCA). Evaluating the elements of decision making while discussing a decision with the patient and documenting their ability in one’s note will enhance clinician comfort and skill in assessing and addressing decision making. There are more complex neuropsychological tests that can be done to test the same areas of function in more detail that are applied by neuropsychologists or in research.

The Nuremberg Code of Ethics states that individuals involved “should [have] the power of choice without the intervention of any element of force, fraud, deceit, duress, overreaching, or other ulterior form of constraint or coercion.”

The legal definition of voluntarism is when there is no evidence that the individual was “unduly” influenced by shared values, inducements, persuasion, or force. Clinicians may be required to judge whether they feel that there is coercion Asking an individual why they are making the decision that they can help to clarify inducements, but the problem of “undue” influence is still a judgement.

Psychologically based influences on decision making include emotional distress, life history, pain and suffering, genuineness, coherence with other life decisions, and experiences of power relationships. Any of these may influence a person in the moment of decision making in ways that can change their decision. Their choice might be different if these issues were to be directly addressed.

Of profound importance is the context of and quality of the interaction during the decision-making process. Components of this interaction include trust, cultural competence, information quality, provider competence, and the quality of communication. These influence the individual’s ability to understand and appreciate the personal impact of information before they can incorporate their own personal and cultural context and come to a decision.

For medical decision making there is often a feeling of subtle or sometimes blatant coercion for a specific decision felt to be most appropriate by the medical personnel. There can be feelings of mistrust and poor-quality communication that lead to misunderstandings. Taking a lesson from narrative ethics, clinicians ought to help the patient answer the how and why

of where they are with a particular decision and aid the patient in making a decision that resonates with their context and values.

Decisional incapacity is task-specific and may be time-limited. Although one may be adjudicated to be either incompetent or competent in the two broad legal categories of person and finance, the ability of an individual to participate in decisions needs to be thought of in more flexible terms. We will discuss incapacity in matters of person (medical decisions and ability for self-care), finance, wills, advance directives, and research.

Because patients have the right to decline medical interventions and they have the right to be informed before consenting to medical treatments, the need to make a medical decision frequently prompts the first assessment of decisional capacity.

Documentation of a formal cognitive test score is not necessary in most cases; a thoughtful interview with the patient and a written description of the areas in which the patient is unable to function is usually sufficient. It may be helpful to specifically comment on the individual’s ability to understand the condition, the treatment alternatives (including no treatment), and their possible outcomes; demonstrate their appreciation of how they apply this information to their current situation; explain how their reasoning and values have helped them form their thinking; and document their choice.

Geriatricians are often confronted with situations where a patient demonstrates an inability to care for self or to accept the help needed to remain be safe in their present environment. To differentiate issues of cognitive impairment versus denial, a formal assessment of decision-making ability may be necessary. A person’s tendency to be “eccentric” is not always easily distinguishable from dangerous behaviors stemming from increasing cognitive impairment and an inability to make decisions around self-care. Gross impairment of cortical function, especially short-term memory, can pose problems for day-to-day function. More subtle, but of high impact, is frontal lobe dysfunction. The inability to plan, initiate action, monitor one’s behavior, and self-correct are essential to being able to care

for oneself. A combination of findings on frontal lobe testing and demonstrated inability to care for oneself is often sufficient evidence for action, especially in combination with an inability to accept a level of care that would keep them safe. Patients who demonstrate an inability to perform functions such as organizing their medications or safely preparing meals (IADL functions) and have the need for the help that will obviate these problems (eg, home care, Meals-on-Wheels) may be regarded as having intact decision making with respect to resolving these issues.

A reasonable approach in this scenario would involve a structured assessment where the patient must demonstrate an ability to understand and appreciate a known functional problem; understand and appreciate the practicality, risks, and benefits of potential options; choose an option; and explain how this choice is preferable to the other options not chosen.

There are times when an individual remains able to make medical decisions and decisions related to self-care but is no longer capable of managing finances. When bills are going unpaid or gross mistakes are made in handling money, someone else will need to take over financial management. A demonstrated problem with finances is usually sufficient to warrant supervision, but an occupational therapist or a neuropsychologist can also assess this function. If the individual has enough insight to understand the problem and a reliable person is available to help, granting that person a POA for finances is sufficient. If the incapacitated person is reluctant to relinquish control, or court monitoring is deemed advisable, then the family or other concerned party should seek a guardian of finance.

The ability to make a last will and testament is felt to be retained even after the ability to handle finances and make decisions has been lost. An individual’s ability to remember what he or she is doing with the estate and to express some logic behind choices is usually sufficient evidence of capability.

The ability to grant someone durable POA for health is similar, in that a patient can indicate who they would be best for this and why they have chosen that person. A Living Will, on the other hand, deals with hypothetical situations that can often be hard even for cognitively intact individuals to fully understand and conceptualize. The clinician must also recognize that even very cognitively impaired individuals may still be able to portray wishes and desires (see “Consent Versus Assent”)

Individuals may be transiently incapacitated for decision making or their ability to recover their cognition may not be known, such as when a patient is delirious or has had a recent stroke. In these situations, the clinician should seek an interim solution. An informal surrogate, the person granted durable POA for health affairs, or a temporary guardian can make decisions while the clinician clarifies the prognosis for decisional capacity. The decisions needed during a time of uncertainty should follow the individual’s prior wishes unless they are unknown and then treatment should fall on the side of aggressive protection of the individual’s life or continued function until the person can make his or her wishes known, or the permanence and extent of the impairment becomes clear.

Even when an individual is no longer able to give informed consent to a procedure or a change in living situation, he or she should still participate in the decision-making process. Substituted judgment is the process that a surrogate (legally appointed or informal) is supposed to apply as the basis for a decision. Substituted judgment enjoins one to consider the patient’s prior wishes and long-held beliefs as the basis for one’s decision, “deciding as they would have decided” (see Chapter 72). Assent refers to the impaired individual’s willingness to cooperate with a plan of care. It is, in essence, a way to take into consideration the individual’s present desires when making a decision. In cognitively impaired adults, there is a continuum of incapacity. An individual who is incapable of understanding the complexities of a situation or decision may retain high levels of understanding around specific aspects of the process and be able to express their opinions. Even very cognitively impaired patients can give indications of what brings them pleasure and what gives them pain.

Clinicians obtaining consent for medical treatment or research protocols may wish to use a combination of surrogate consent and patient assent (shared decision making). This may be essential in some cases where the patient’s ability to cooperate will be necessary in order to carry out the treatment or procedure.

An individual’s ability to consent to participate in research is complex. Because the risks and benefits of being in a research study are more abstract, decisional capacity must be even greater than that for accepting or declining an established medical treatment. This is an important time for dual decision making as outlined in the earlier section. It is also important to establish the voluntarism of the consent. Asking why an individual is volunteering (or a surrogate is volunteering the individual) for a research protocol is vital.

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Prevention and screening hold the promise of maintaining health by intervening before an illness can cause symptoms. Some preventive interventions, such as influenza vaccination, have truly minimal risks and clear public health benefits. However, many other interventions, such as cancer-screening tests, impose risks and burdens on patients, complicating the decision on who should (and should not) receive the intervention. For interventions with minimal risks, targeting is less important since many patients will benefit and few (or none) will be harmed. In contrast, for interventions with some risks or burdens, targeting is critical since some patients may be more likely to be harmed than helped by the preventive intervention.

In this chapter, the authors will present the evidence for several preventive interventions in older patients. First, the authors will focus on preventive interventions that impose some risks and burdens on patients, starting with a framework for targeting these preventive interventions and then focusing on the benefits and risks for each preventive intervention in greater detail. These interventions include cancer screening as well as treatment for asymptomatic chronic conditions such as hypertension or diabetes. Second, the authors will review the evidence for interventions with minimal risks. These interventions include behavioral and lifestyle modification as well as immunizations.

Screening for geriatric syndromes such as falls and incontinence are discussed in detail in their respective chapters.

One challenge of appropriately targeting prevention in older adults is that few studies of preventive interventions have enrolled persons older than 75 years. The absence of age-specific data requires clinicians to extrapolate data about the benefits and harms of preventive interventions in younger persons and apply it to older persons. Furthermore, even if trials suggest that the effectiveness of a preventive intervention is similar in younger and older populations, challenges remain about how to apply data from trials to an individual older person. Trials show the average effectiveness of an intervention, but they generally do not address individual patient characteristics, such as comorbid conditions or functional status, which may change the likelihood of receiving benefit or harm from a preventive intervention. Given these challenges, the need to individualize prevention and screening decisions is especially important for older people, because individuals become increasingly heterogeneous in their particular combination of health, function, remaining life expectancy, and values with advancing age.

potential harms of the intervention, and the expected time-to- benefit of the intervention.

The following framework can help individualize prevention and screening decisions so that patients who are most likely to benefit receive the intervention while patients who are more likely to be harmed avoid the intervention and avoid being harmed, and is summarized in Figure 11-1.

FIGURE 11-1. Algorithm for decisions on preventive medical interventions in older adults.

First, estimate life expectancy. By definition, prevention involves an intervention in the present to avoid illness in the future. Many preventive interventions expose patients to risks and burdens immediately for the promise of improved health later. However, older patients with a limited life expectancy may be unlikely to survive to benefit from prevention. For example, finding an asymptomatic cancer in a person who will die of something else before the cancer would become symptomatic does not benefit the person and may cause considerable harm. Thus, the first step in determining whether a preventive intervention may help an older person is to determine their overall life expectancy.

In estimating life expectancy, it is useful to have a general idea of the distribution of life expectancies at various ages. For example, when estimating the life expectancy of an 80-year-old woman, it is useful to know that approximately 25% of 80-year-old women will live more than 13 years, 50% will live at least 9 years, and 25% will live 5 years or less. Figure 11-

2 presents the upper, middle, and lower quartiles of life expectancy for the US population according to age and sex, and illustrates the substantial variability in life expectancy that exists at each age. Although it is impossible for clinicians to predict the exact life expectancy of an individual person, it is possible to use clinical judgment to make reasonable estimates of whether a person is likely to live substantially longer or shorter than an average person in his/her age cohort. Such estimates, while not perfect, would allow for better estimations of potential benefits and harms of screening than focusing on age alone.

FIGURE 11-2. Upper, middle, and lower quartiles of life expectancy for men (A) and women

(B) at selected ages. (Data from Arias E. United States Life Tables, 2017. Natl Vital Stat Rep. 2019;68[7]:1–66.)

In addition, validated mortality risk calculators may help clinicians estimate the life expectancy of individuals better than clinical judgment alone. A systematic review found 16 general mortality risk calculators that have been developed and validated for older adults, and there are numerous risk calculators specific to life-limiting conditions (eg, cancer, dementia, or severe heart or lung disease). These mortality risk calculators have been gathered at https://eprognosis.ucsf.edu/index.php, allowing users to input a given patient’s data such as age, comorbidities, and functional limitations to obtain an evidence-based estimate of mortality risk and life expectancy.

For preventive interventions that expose patients to immediate risks or burdens with delayed benefits, the time-to-benefit can be defined as the time between the intervention (when harms are most likely) to the time when improved health outcomes are seen. Just as different interventions have different magnitudes of benefit, different preventive interventions have

different times to benefit. Unfortunately, although there are numerous widely accepted measures of the magnitude of benefit (eg, relative risk, odds ratio, and absolute risk reduction) there are no standardized measures of the time- to-benefit. Studies have focused on answering the questions, “Does it help?” (ie, p < 0.05?) and “How much does it help?” (ie, what is the relative risk reduction), generally ignoring the question, “When does it help?”

Because studies have generally focused on the magnitude of benefit, the time-to-benefit for many preventive interventions is unclear. Survival meta- analyses of screening trials have estimated the time-to-benefit for a few cancer-screening interventions. For preventive interventions where survival meta-analyses have not been conducted, the time-to-benefit can be estimated by reviewing Kaplan-Meier survival curves for the intervention and control groups. The point at which the curves last clearly separate provides a reasonable estimate of the time-to-benefit for a preventive intervention.

Third, review the most likely benefits of prevention. If a patient is likely to live long enough to benefit from a preventive intervention, the next step is to consider the potential benefits. For example, the main benefit of cancer screening is the reduction in cancer mortality experienced by a few people whose early-stage disease is detected and treated, which otherwise would have been lethal during their remaining lifetime. While the impact of cancer screening on quality of life or functional decline has not been studied, there is good evidence that mammography, fecal occult blood testing (FOBT), and Papanicolaou (Pap) smears are effective in reducing cancer- specific mortality. However, the strength of the evidence that these tests are effective in older adults is limited by the small number of older patients included in screening trials. In addition, even screening tests likely to be effective in older populations may not provide survival benefit to individuals with life expectancies that are shorter than the time-to-benefit from screening.

Fourth, review the most likely harms of prevention. Since many preventive tests pose both direct and indirect harms, the potential benefits of interventions, such as cancer screening, must be weighed against the potential harms of screening. Harms that would be accepted to treat a symptomatic person with known disease are less acceptable when they are caused by screening tests, which benefit only a few individuals but expose all screened individuals to the potential harms.

Individuals who are found not to have cancer after work-up of an abnormal screening result (false-positive result) clearly have experienced

harm from screening, as they were subjected to physical and psychological distress from additional testing and procedures that would not have been necessary had they not been screened. However, what is often forgotten is that in older persons some of the greatest harms from screening occur by finding and treating cancers that would never have become clinically significant. The risk of identifying an inconsequential cancer (ie, overdiagnosis) increases with decreasing life expectancy as well as with the increasing likelihood that screening will detect certain neoplasms that are unlikely to progress to symptoms in older persons, such as ductal carcinoma in situ (DCIS). Fewer than 25% of DCIS lesions progress to invasive cancer within 5 to 10 years, yet because of the inability to distinguish which lesions will progress, many older women with DCIS will undergo surgery. Women who have surgery for DCIS that would never have become symptomatic in their lifetime have suffered serious harm from screening.

In addition to physical harms, the psychological distress caused by preventive interventions should be considered. For cancer screening, the potential psychological harms range from the emotional pain of a diagnosis of cancer in persons whose lives were not extended by screening, through the alarm of false-positive results to the stress of undergoing the screening test itself. Many older persons may have cognitive, physical, or sensory problems that make screening tests and further work-up particularly difficult, painful, or frightening. Considering factors that increase the likelihood of harm is vital to making appropriate preventive decisions.

Finally, review benefits and harms with each patient, integrating the patient’s values and preferences into the decision. The final step of the framework for individualizing preventive decisions is to assess how individuals value the potential harms and benefits of a preventive intervention and to integrate their preferences into the decision. Because many cancer-screening decisions in older persons will not be answered solely by quantitative assessments of benefits and harms, talking to older persons about their values and preferences is especially important. The value placed on different health outcomes will vary among older people, as will preferences for screening. For example, some women undergoing screening mammography value “peace of mind” after a negative screening result, whereas women with dementia likely receive no such comfort. In considering the benefits versus harm of screening, clinicians must elicit how individuals value the tradeoffs among longer survival, comfort, and functional status.

Clinicians should consider a person’s usual approach to medical decision making to decide how to approach the discussion of preventive interventions. In some cases, clinicians will need to learn a person’s values, apply them to the known benefits and harms of a preventive intervention, and make a formal recommendation. For other people, the clinician will want to discuss the benefits and harms with the person and allow the person to apply his/her values to the outcomes and come to a decision together. For people with dementia, discussion about preferences should be held with an involved caregiver. However, it should be remembered that despite being unable to articulate consent, many persons with dementia can still effectively communicate refusal. Assent from a person with dementia is essential if invasive or potentially harmful testing or treatments are being considered. If a person with dementia is likely to be frightened or agitated by a preventive test, the caregiver and clinician should forgo the test. Also, for screening tests there should be a general discussion prior to screening about the possible procedures and treatments that may be required after an abnormal screening result. Persons who would not want further workup or treatment of an abnormal result should not be screened.

In summary, the authors recommend estimating patient’s life expectancy and then comparing that life expectancy to the time-to-benefit for a specific preventive intervention. The benefits and harms of prevention, such as cancer screening, should be reviewed to determine whether specific patient factors are present (such as excellent health or cognitive impairment) which suggest that a patient is more likely to benefit or be harmed by screening than the average patient. The benefits and harms should be incorporated into a discussion with the patient regarding his/her values and preferences. If the life expectancy is more than the time-to-benefit, the patient has a substantial chance of benefit and thus a preventive intervention should be encouraged. If the life expectancy is less than the time-to-benefit, the patient is more likely to be harmed than helped by a preventive intervention and thus should not be offered. If the life expectancy approximates the time-to-benefit, a patient’s values and preferences are especially important and should play the dominant role in the decision whether to perform a preventive intervention or not.

Time -to-be nefit for screening mammography A survival meta-analysis of randomized trials of screening mammography suggested that it takes 11 years to prevent 1 breast cancer death after screening 1000 women. Since the rate of serious complications after screening mammography appears to be approximately 1 in 1000, screening mammography may be most appropriate for women with a life expectancy greater than 10 years. Further, modeling studies suggest it is cost-effective to conduct biennial screening mammography as long as an older woman has a life expectancy of at least 9.5 years.

Benefits of breast cancer screening Mammography is the only screening modality that has been shown in randomized controlled trials to decrease breast cancer mortality. Mammography may detect cancers more frequently and accurately in older women. A pooled meta-analysis of trials demonstrated an overall relative risk reduction in breast cancer-related mortality of 27% for women between the ages of 50 and 69. Only one randomized trial examining mammography included a small number of women age 70 to 74 and found no breast cancer-specific mortality reduction in this age group, and no trials have included women older than 75 years. Consequently, data from trials in younger people must be extrapolated to older people.

Harms of breast cancer screening Among women aged 75 and older who undergo biennial screening mammography, the cumulative probability of a false- positive mammogram over 10 years ranges from 14% to 27% and this risk nearly doubles if women are screened annually. False-positives can cause anxiety and uncomfortable downstream testing such as breast biopsies, which can be distressing to older women with cognitive impairment who do not understand what is being done to them. The risk for overdiagnosis (finding a malignancy in a patient who would never have been affected clinically by the malignancy in the absence of screening) increases with age because life expectancy decreases and there is a higher proportion of slower growing cancers in older women. One study estimated the rates of overdiagnosis to be 12% to 29% for women who stop biennial screening at 74 years, 17% to 41% for women who stop at 80 years, and 32% to 48% for women who stop screening at 90 years. Frail older women are at increased risk for experiencing harms from screening. One study of frail community-living women found that 17% experienced burden from screening mammography as

a result of work-up refusals, false-positive results, or overdiagnosis. Women with multiple comorbid conditions are also likely to experience adverse effects from surgery, radiation, and chemotherapy.

TABLE 11-1 ¦ GUIDELINE RECOMMENDATIONS FOR CANCER SCREENING IN OLDER ADULTS

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Time -to-be nefit for colorectal cancer screening A survival meta-analysis of randomized trials of screening fecal occult blood testing for colorectal cancer suggested that it takes 10 years to prevent 1 colorectal cancer death after screening 1000 persons. Since the rates of serious complications after colorectal cancer screening also appear to be approximately 1 in 1000, colorectal cancer screening may be most appropriate for persons with a life expectancy greater than 10 years. Randomized trials of screening flexible sigmoidoscopy show similar times to benefit. Ongoing trials of screening colonoscopy will provide additional information about whether time to mortality benefit with screening colonoscopy is similar to screening fecal occult blood testing and screening sigmoidoscopy.

Benefits of colorectal cancer screening Methods for screening for colorectal cancer include FOBT, fecal immunochemical testing, flexible sigmoidoscopy, and colonoscopy. Guaiac-based fecal occult blood testing has the strongest evidence for screening efficacy based on three European randomized controlled trials showing reductions in colorectal cancer-specific mortality of 11% to 16%, and a large US trial showing reductions of 22% to 32% overall, and a 53% reduction among adults 70 to 80 years old. Randomized trials of screening sigmoidoscopies every 3 to 5 years suggest similar mortality benefits. Polypectomy during colonoscopies can prevent colorectal cancer in addition to early detection of colorectal cancers.

Harms of colorectal cancer screening Approximately 1 of 10 older adults who submit a screening guaiac-based fecal occult blood testing will have a false- positive result. Colonoscopy is the standard work-up following a positive fecal occult blood testing and may have serious complications, such as perforation (1/1000), serious bleeding (3/1000), cardiorespiratory events (12/1000), and death (1/1000). Complications may be higher if polypectomy is performed or if persons are in poor health. Discomfort from flexible sigmoidoscopy or colonoscopy may occur, and many older persons may experience substantial distress from the bowel preparation, including dizziness, nausea, and fecal incontinence.

Recommendations The USPSTF recommends colorectal cancer screening for all older adults age 45 to 75 and that screening decisions should be selectively offered to persons 76 to 85 years based on overall health and prior screening history. The American Cancer Society recommends screening begin at age 45, continue until age 75 for individuals with greater than a 10-year life

expectancy, individualized decisions for adults age 76 to 85, and screening be discouraged if older than 85. Most guidelines recommend annual screening fecal occult blood testing or fecal immunochemical testing and/or flexible sigmoidoscopy every 5 years or colonoscopy every 10 years for average risk (see Table 11-1). There is no evidence available to determine which screening method is preferable or when screening should stop.

Time -to-be nefit for cervical cancer screening A cluster randomized trial of younger women (age 30–59) suggests that cervical cancer screening with HPV testing leads to mortality reductions in 2 to 3 years. In contrast, screening with cervical cytology appears to lead to mortality benefits in 6 to 7 years. There are no data about the time-to-benefit for cervical cancer screening in women 65 years and older. The main consideration for cervical cancer screening is whether an older woman has received screening during her reproductive years because the likelihood an older woman will die of cervical cancer is remote if she has had normal screens in the past. Routine vaccination for human papilloma virus (HPV) strains related to cervical cancer occurrence in younger adults is expected to lower the incidence of cervical cancer in future generations.

Benefits of cervical cancer screening The principal method for screening for cervical cancer is through the use of cervical cytology. Since screening with Pap smears was initiated, population studies in the United States show a 20% to 60% decline in mortality rates from cervical cancer. Decision models suggest that older women who have had repeated normal Pap smears during their reproductive years do not benefit from continued Pap testing beyond age 65 or 70. However, these models make variable recommendations about the number of normal Pap smears required prior to stopping screening.

Harms of cervical cancer screening False positives are common among older postmenopausal women. In one study of 2561 older women with a normal prior Pap smear, 110 women had an abnormal pap smear within the subsequent 2 years and only 1 was a true positive; the positive predictive value of an abnormal cervical smear is less than 1%. Harms of false-positive results include needless patient concern and invasive procedures, such as colposcopy or biopsy. Discomfort and anxiety during Pap smears also occurs as does the identification and treatment of clinically unimportant cervical lesions given the slow growing nature of cervical cancers and the possibility of regression of low-grade cervical lesions.

Recommendations Guidelines recommend cervical cancer screening with cytology every 3 years for women age 21 to 65. Combining cytology testing with HPV testing every 5 years may provide added benefit (see Table 11-1). Guidelines recommend that Pap smears be discontinued in women older than age 65 who have had adequate prior screening, defined as three consecutive negative cytology results or two consecutive negative HPV co-tests within 10 years of stopping screening, with the most recent test occurring within 5 years of stopping. The authors recommend cervical cancer screening in women older than age 65 who have not had adequate prior screening and are healthy enough to undergo cervical cancer treatment if cancer is found.

Time -to-be nefit for lung cancer screening Two large trials of low-dose lung CT scans show reductions in lung cancer-specific mortality after 6 years. For chest x-rays, one large trial found no lung cancer mortality benefit.

Potential benefits The National Lung Screening Trial (NLST) found that among current and former heavy smokers age 55 to 74, low-dose lung CT scans

decreased lung cancer mortality by 20%. Specifically, for 1000 persons screened, 4 lung cancer deaths would be avoided in 6 years. The Dutch- Belgian Lung Cancer Screening (NELSON) Trial of low-dose lung CT scans among current and former heavy smokers found a 24% reduction in lung cancer–specific mortality at 10-year follow-up, and 3.3 lung cancer deaths avoided per 1000 participants.

Potential harms False positives are common with low-dose CT scans of the lung; in one trial 39% of people who received a CT scan had at least 1 positive test result and 96% of positive results were false positives. False positives may lead to unnecessary invasive testing, including surgical procedures and biopsies. Complications after invasive lung procedures may occur in 1 in 5 older adults, and rates may be higher for older adults in worse health compared to those who are younger or healthier. Reported rates of overdiagnosis range from 3% to 9%, although this is an active area of study. Additional harms include anxiety from false-positive results, frequent need for follow-up and repeat imaging, financial strain, and radiation exposure.

Recommendations The American Cancer Society and USPSTF recommend annual low-dose CT scans for lung cancer screening in adults 55 to 74 years old (or up to 80 in USPSTF guidelines) who have a 30-pack-year history and currently smoke or quit within the last 15 years. Guidelines suggest avoiding screening in older adults with a short life expectancy (< 10 years) or comorbidities that would make curative surgery or cancer-directed therapies not a reasonable option (see Table 11-1). The authors recommend low-dose CT scans when older adults are at high risk of lung cancer, are current or former heavy smokers, and have a low risk of a competing cause of death.

false positive results (including in the thyroid and other organs), potential downstream interventions, and the need for frequent follow-up for nodule tracking.

Although prostate-specific antigen (PSA) testing is frequently performed, there is conflicting evidence and guidelines regarding the benefits and harms of PSA testing. The mortality benefit is small and takes over 10 years to be realized. In contrast the harms from testing can include anxiety, unneeded prostate biopsies (associated with hematuria, pain, and infections), and overdiagnosis and unnecessary treatments of screen-detected cancers

(associated with urinary incontinence, sexual dysfunction, and premature death). The USPSTF and American Cancer Society recommend that men age 55 to 69 make an individualized decision about PSA screening after discussion with a clinician and consideration of life expectancy (typically greater than 10–15 years), and recommend against screening in men older than 70 years old (see Table 11-1). The authors do not recommend routine screening for prostate cancer in older men based on the available evidence.

Treatment of asymptomatic chronic conditions such as hypertension and diabetes also impose immediate risks and burdens on patients for the promise of delayed benefits. More intensive glycemic control appears to decrease the risk of microvascular complications many years later. However, more intensive glycemic control clearly increases the risk for serious hypoglycemia immediately. Similarly, improved blood pressure control appears to decrease the risk of heart failure and stroke. However, initiating antihypertensive medications appears to increase the risk of hip fracture in the first 45 days. Thus, for asymptomatic chronic conditions, the risks and burdens of treatment often occur immediately while the benefits are not observed for years. This suggests that treatment for asymptomatic conditions can also be viewed as prevention, and should be targeted toward patients with an extended life expectancy who have a reasonable chance of benefiting from the delayed benefits.

Unfortunately, there is tremendous uncertainty surrounding the time-to- benefit for various interventions. Long-term follow up studies of more intensive glycemic control suggests that it take 8 to 15 years for the clinical benefits to be seen (Table 11-2). Studies of more intensive blood pressure control suggests that it take 1 to 3 years for clinical benefits to be seen. For HMG-CoA Reductase inhibitors (“statins”), the time-to-benefit appears to be dependent on clinical situation, with nearly immediate (< 3 months) benefit in patients with recent myocardial infarction and increasing to several years for primary prevention of major adverse cardiovascular events (see Table

TABLE 11-2 ¦ ESTIMATED TIMES TO BENEFIT FOR THE TREATMENT OF COMMON CHRONIC CONDITIONS

In summary, treatments for many asymptomatic chronic medical conditions impose immediate risks and burdens on patients with the promise of delayed benefits. Thus, the framework of individualizing prevention also applies to the treatment of these asymptomatic conditions, and treatment of these asymptomatic conditions should be targeted to those older adults whose life expectancy exceeds the time-to-benefit.

In contrast to screening interventions, the risks associated with immunizations are much lower than the benefits. Thus, targeting is less important and nearly all older adults should receive the pneumococcal vaccination, annual influenza vaccination, and zoster vaccination.

Pneumococcal infections represent a major cause of morbidity and mortality in older adults. The US Advisory Council on Immunization Practices (ACIP) recommends all adults older than age 65 sequentially receive both the Pneumococcal Conjugate Vaccine (PCV13) followed in 6 to 12 months by the Pneumococcal Polysaccharide Vaccine (PPSV23). Minor local reactions such as pain or erythema are common with both vaccines; more serious side effects are rare. The ACIP also recommends pneumococcal vaccination for adults younger than 65 who have certain risk factors such as cigarette smoking, diabetes mellitus, or chronic lung disease.

The influenza virus causes annual epidemics of acute respiratory illnesses every winter that disproportionately affects older adults. Vaccination has been shown to decrease the morbidity and mortality associated with influenza and is recommended for all persons older than 6 months. There is some evidence that a high-dose influenza vaccine may be more effective in eliciting immunogenic response in adults older than age 65. The most common adverse events include local soreness. The risk of Guillain-Barre syndrome after influenza vaccination appears small, with estimates of 1 to 2 excess cases per 1 million persons vaccinated.

Tetanus is cause by the neurotoxin expressed by Clostridium tetani when the ubiquitous bacteria spores are inoculated into tissues with trauma or deep puncture wounds. Tetanus toxoid vaccine is effective, but waning immunity has led to the large proportion of cases to occur in adults older than 60 years. Diphtheria is a rare, acute respiratory illness caused by a toxin expressed by Corynebacterium diphtheria. National serosurvey between 1988 to 1994 suggested that only 30% of adults age 60 to 69 had appropriate diphtheria antitoxin concentrations. ACIP recommends tetanus/diphtheria (Td) or Tdap revaccination every 10 years for all older adults.

Pertussis or whooping cough is a highly contagious respiratory illness that is underdiagnosed and underreported, especially in older adults. Studies suggest that acellular pertussis vaccination is equally effective among older adults as younger adults with similar low rates of adverse events and high rates of pertussis antibodies. ACIP recommends a one-time booster dose of pertussis vaccination after age 65.

In summary, the ACIP recommends that all adults receive Td (tetanus/diphtheria) or Tdap booster every 10 years. In addition, adults older than age 65 should receive a one-time dose of Tdap (tetanus/diphtheria/acellular pertussis) if they have not received pertussis revaccination after age 19 in lieu of Td vaccination.

Reactivation of herpes zoster is common (30% lifetime risk) and can result in significant morbidity from complications such as postherpetic neuralgia and ophthalmic zoster. The two-dose recombinant zoster vaccination (RZV)

appears to be quite effective in persons 70 years or older, with an efficacy for prevention of herpes zoster of 91% and prevention of postherpetic neuralgia of 91%. In comparison, the one-dose live zoster vaccine (ZVL) has an efficacy of 38% among adults 70 years or older and prevention of postherpetic neuralgia of 67% (0.1% vaccine vs 0.4% control). The most common adverse reactions to zoster vaccinations are local injection site reactions (9% in RZV and 1% in ZVL); serious adverse reactions are rare.

The ACIP recommends the two-dose RZV vaccination for adults age 50 and older, including those who have previously received the ZVL vaccination.

Like immunization, healthy behaviors have few, if any, adverse outcomes, meaning that they can be recommended to nearly all older adults. However, unlike immunizations which are initiated and provided by the health care system, healthy behaviors require a personal commitment from individual patients. While the advice and encouragement from health care professionals are important, the effectiveness of any behavioral modification requires the individual patient to accept primary responsibility for initiating and maintaining healthy behaviors. A summary of recommendations in healthy behavior counseling for older adults is included in Table 11-3.

TABLE 11-3 ¦ HEALTH BEHAVIOR SCREENING AND INTERVENTIONS IN OLDER ADULTS

A healthy diet can contribute to an increase in life expectancy, better health, and quality of life as meals can be a source of pleasure and social engagement. Healthy diets have shown the potential to lower blood pressure and blood cholesterol. Optimal diets have also been associated with lower risk of chronic diseases, notably CAD, diabetes, obesity, and some forms of cancer. National Health and Nutrition Examination Survey (NHANES) III data show potentially important decreases with age in median protein and zinc intakes as well as intakes of calcium, vitamin E, and other nutrients.

Malnutrition can often be undetected and subclinical nutrient deficiencies can adversely affect health and physical functioning. Screening for nutritional status should therefore occur routinely and include measuring body weight, weight loss, and considering screening tools such as the Mini Nutritional Assessment (MNA) or Malnutrition Screening Tool (MST).

Older adults can be counseled on the traditional Mediterranean diet, dominated by consumption of olive oil, vegetables, nuts, and fruits, which meets criteria for a healthy diet and is associated with prevention of progression of cardiovascular disease and reversal of the metabolic syndrome. Either antioxidants or fiber may affect a reduction in the transient oxidative stress associated with macronutrient intake. Prevention of malnutrition may require addressing polypharmacy or medications that can contribute to changes in taste or anorexia, monitoring dental health, addressing food insecurity, addressing depression, reducing isolation at mealtimes, and avoiding unnecessarily restricted diets (limiting salt, fat, or sugar), which can contribute to inadequate eating. The latest edition of Nutrition and Your Health: Dietary Guidelines for Americans, available online at http://www.health.gov/dietaryguidelines/, can serve as a reference for providers in counseling adults about healthful eating patterns.

Physical activity and physical fitness can help prevent or delay the onset of chronic illnesses such as CAD, type II diabetes, osteoporosis, obesity, and cognitive impairment; protect against the development of functional decline; improve mood; reduce stress; and, perhaps, increase life expectancy.

Physical activities that improve endurance, strength, and flexibility will delay impairments in mobility and may preserve the ability to perform tasks of daily living. Regular, moderate-intensity physical activity increases

muscle mass and oxidative capacity, improves immune function, increases antioxidant defense against oxygen free radicals, and reduces oxidative stress. The current recommendation that every American exercise at least 30 minutes on most, and preferably all days, derives from evidence that even moderate physical activity is associated with a substantial drop in all-cause mortality. The cumulative, lifetime activity pattern may be the most influential factor in terms of providing protection from most diseases, especially those with a long developmental period, as well as mediating secondary disease complications associated with CAD, diabetes, and hypertension. The benefits of physical activity appears to outweigh the risks for nearly all older adults, including older adults at high risk for falling. For older adults with joint pain, arthritis, or cardiovascular disease, individualized guidance from clinicians may help patients to safely start a physical activity regimen.

Despite an enormous amount of information about the positive effects of exercise in preventing disease and increasing life expectancy, the majority of adults do not engage in regular, sufficient physical activity. Furthermore, aging appears to be associated with a rise in the prevalence of inactivity, especially among women, such that by age 75, one in three men and one in two women engage in no regular physical activity. Societal changes over the past 50 years, including increased dependence on cars for transportation, the advent of television and computers, and rise in number of desk jobs, have virtually engineered physical activity out of the daily routines of many Americans. Thus, encouraging and prescribing physical activity for adults of all ages is imperative and can be viewed as a central tenet of preventive gerontology.

Regular participation in activities of moderate intensity (such as brisk walking, climbing stairs, scrubbing floors, yard work), which increase caloric expenditure and maintain muscle strength, is recommended, as it is activity of moderate intensity that appears to allow health benefits to accrue. Current national guidelines suggest at least 30 minutes of moderate-intensity exercise on 5 or more days per week (Centers for Disease Control and Prevention [CDC]) or vigorous-intensity exercise (such as swimming laps, bicycling more than 10 miles per hour, jogging, or running) for 20 or more minutes on 3 or more days per week. The CDC, American College of Sports Medicine, and Surgeon General further state that daily physical activity

Several psychological and environmental factors determine physical activity behavior throughout the life span. Self-efficacy, or confidence in one’s ability to perform a particular behavior (in this case, regular exercise), is strongly associated with both adoption of and adherence to physical activity among adolescents, young adults, and older adults. Strategies suggested to enhance self-efficacy, such as assessing readiness for exercise using a behavior change philosophy, using motivational interviewing techniques, weekly action planning and feedback, collaborative problem- solving, and addressing barriers to exercise may all enhance self-efficacy for exercise. These techniques can be learned and implemented by health care providers. Affective disorders such as depression and anxiety are inversely associated with physical activity participation at any age. Thus, evaluation for the presence of these conditions and institution of treatment may be necessary before adoption of an exercise program can occur. Social influences on physical activity appear to be strong throughout the life span.

Peer reinforcement is particularly important in youth, while social support from spouses, friends, and community organizations (eg, Silver Sneakers program) is correlated with vigorous activity in younger and older adult populations. Finally, environmental factors, particularly safety and accessibility, influence activity participation across the age span. These latter factors are increasingly becoming a focus of community intervention efforts.

Ongoing involvement in a social network permits social contact (integration), the provision of social support, and the opportunity for social influence, and is associated with positive health outcomes and self-assessed well-being.

functions, getting together with friends and family, and going to church, meaningful social roles are defined and reinforced, creating a sense of belonging and identity. Measures of social integration or “connectedness” are powerful predictors of mortality likely because ties give meaning to an individual’s life by enabling and obligating them to be fully involved in their community and thereby to feel attached to it. Social connections have been further linked to reduced risks of cognitive impairment.

There are several pathways by which social networks are thought to influence health: (1) a health behavioral pathway; (2) a psychological pathway; and (3) a physiologic pathway. Regarding the health behavioral pathway, social ties have been shown to influence the likelihood that certain behaviors will be adopted and that behavior will change (see also Chapters 4 and 25). For example, marriage and friendship ties have been shown in several studies to promote a healthier diet, more regular exercise, less smoking and drinking, and more cancer screening. Notably, not all social ties are positive, and some can negatively impact health, for example, the presence of a smoker in one’s social network has been associated with greater relapse in efforts to quit and family members can be involved in emotional, physical, or financial elder mistreatment. A second mechanism by which social networks influence health is via psychological pathways.

Loneliness is the emotional distress that arises from a perception that one’s social relationships are inadequate. Loneliness has been independently linked to psychological distress, physical symptoms such as pain, and mortality. In addition, social ties can provide emotional support to protect against depression or anxiety, moral support in a crisis, or reduce day-to-day stress through social connection (eg, calling a friend about an odd symptom to get advice). Just knowing one has support to call on in times of need can reduce stress. A third mechanism by which social networks influence health is via physiologic pathways. Social relationships may influence health via effects on the hypothalamic–pituitary–adrenal axis, altering immune responses and cardiovascular reactivity. For example, a low number of contacts with acquaintances is associated with high resting plasma levels of epinephrine, and people with low social support have been found to have higher levels of urinary norepinephrine, regardless of their level of stress.

The authors recommend that clinicians should ask individuals about their social connections and if they feel lonely. Clinicians can directly address social needs by asking if individuals would like more social contact, what

types of contact they prefer, and connecting individuals to programs to enhance social connections or support. Clinicians can facilitate social connections by identifying and addressing barriers to interacting with others such as hearing impairment, functional impairment, or cognitive impairment. Preventive strategies that encourage maintaining or enhancing existing relationships may in certain cases be more effective than trying to develop new relationships when an individual is already isolated or lonely.

Depression in older adults is common, underdiagnosed, and often inadequately treated. Rates of depression vary according to the diagnostic criteria used, but 2% of adults older than age 55 meet criteria for major depression while 14% report depressive symptoms. Most depression is recognized and treated in primary care; however, studies suggest that depression is often undiagnosed. Further, depression treatment has been shown to improve outcomes. The USPSTF recommends screening adults for depression in clinical practices that have systems in place to ensure accurate diagnosis, effective treatment, and follow-up.

Tobacco use is the largest single preventable cause of illness and premature deaths in the United States. Illnesses related to tobacco use (coronary artery disease [CAD]; cancers of the lung, larynx, oral cavity, esophagus, pancreas, and urinary bladder; stroke and chronic obstructive pulmonary disease) account for one in every five deaths in the United States. Evidence from NHANES indicates that tobacco use predicts shorter survival time for middle-aged (45–54 years) and older (65–74 years) men. Tobacco use can also multiply the risk associated with other carcinogenic agents; for example, heavy alcohol consumption, associated with esophageal cancer, carries an even greater risk when combined with cigarette smoking.

Tobacco dependence should be viewed as a chronic condition requiring ongoing assessment and repeated intervention. However, effective treatments are available that can lead to long-term, and in some cases, permanent abstinence. Studies have shown that individuals at any age can benefit from

quitting the tobacco habit. Benefits include reduction in the risk of CAD, malignancy, stroke, and even hearing loss, along with improved pulmonary function, arterial circulation, and pulmonary perfusion.

Studies have found that only about 35% of adults are routinely asked about their tobacco habits or counseled to quit if they use tobacco. If providers do advise patients not to use tobacco, as many as 25% will quit or reduce the amount they use. Thus, providers should ask all patients at each clinic visit about tobacco use and advise all tobacco users about the importance of quitting, emphasizing factors that have been found to contribute most to successful attempts to quit: health concerns (symptoms); a desire to set an example for children; the expense of the habit; odor of breath, home, and clothing; and loss of taste for food. Providers should then assess a patient’s willingness to attempt to quit. Patients who are unwilling to attempt to quit should be provided with a brief intervention designed to increase their motivation to quit.

Patients who are willing to quit should be provided with treatments that have been identified as effective. First-line pharmacotherapies that have been shown to increase smoking cessation include nicotine replacement (gum, inhaler, nasal spray, or patch), varenicline, and bupropion. Varenicline and bupropion appear to lead to increased rates of neuropsychiatric side effects including suicidal ideation. Thus, patients started on either medication should be monitored for neuropsychiatric symptoms including changes in behavior, agitation, depressed mood, hostility, and suicidal ideation.

Epidemiological studies support a survival benefit associated with moderate (up to two 8-ounce drinks per day) alcohol consumption, primarily through reduction of cardiovascular risk, including elevation of high-density lipoprotein (HDL) cholesterol. Although initial studies suggested that red wine may be especially beneficial, more recent studies suggest that the type of alcohol is not as important as the amount of alcohol intake and the pattern of use.

However, consumption of alcohol beyond a moderate level can induce adverse effects on every organ system, including increased risk of hypertension; breast, colon, esophageal, liver, and head and neck cancer; cirrhosis; gastrointestinal bleeding; pancreatitis; cardiomyopathy; seizures; cerebellar degeneration; peripheral neuropathy; cognitive dysfunction;

insomnia; depression; and suicide. Nearly 15% of adults older than age 65 drink more than the recommended moderate level (> 7 drinks/week or binge- drinking). Counseling about problem drinking following a few screening questions is a high-impact, cost-effective intervention. Screening can be accomplished by taking a careful history of alcohol use or by using a standardized screening questionnaire. All adults should be counseled on the health risks associated with excess alcohol consumption as well as the risk of injury (ie, motor vehicle crashes or other equipment-related injury) after drinking alcohol. Nondependent heavy drinkers as well as those with alcoholism (a chronic illness involving a state of dependency) should be counseled about the benefits of decreasing alcohol intake. Brief counseling by primary care providers can result in a significant reduction in alcohol use. Dependent drinkers should be referred to formal alcohol treatment programs and considered for a trial of naltrexone, an opioid antagonist that reduces the pleasurable effects of alcohol and may reduce relapse to heavy drinking.

In adults, obesity is defined as a body mass index (BMI) of 30 kg/m2 or more; overweight is a BMI of 25 to 30 kg/m2 or more. Research suggests that although obesity and underweight are associated with increased mortality, being overweight (BMI 25–30) is not associated with increased mortality at

any age. Further, increasing evidence suggests that being obese may not be as dangerous for older adults as younger adults. NHANES data suggest that for adults age 25 to 59, BMI more than 35 compared to BMI 19 to 25 nearly doubles the risk of all-cause mortality with a relative risk of 1.8. In contrast, for adults older than age 70, the all-cause mortality risk with BMI more than 35 is not statistically different from BMI 19 to 25 with a relative risk of 1.2. In fact, for adults older than age 70, being underweight (BMI < 19) was associated with higher mortality than being obese (BMI > 35). Thus, the optimal BMI for older adults appears to be slightly higher than the optimal BMI for younger adults.

For older adults, obesity is also a risk factor for impaired mobility and other functional limitations, disabling conditions such as osteoarthritis; sleep apnea; gallbladder disease; nonalcoholic fatty liver disease; and cancers of the breast, endometrium, and colon. Moreover, those who are obese may suffer from social stigmatization, impaired social interaction, depression, and low self-esteem. Thus, regardless of the relationship between obesity

and mortality in older adults, counseling obese patients to lose weight is likely to be beneficial.

Because treatment and reversal of obesity is challenging, primary prevention is warranted. Efforts to maintain a healthy weight should start early in life and continue throughout adulthood, as this is likely to be more successful than efforts to lose substantial amounts of weight and maintain weight loss once obesity has developed. Data from NHANES I suggest that getting adequate rest may be important in obesity prevention. Sleeping less than 7 hours a night was shown to be a risk factor for subsequent obesity.

This may be related to altered levels of leptin and ghrelin, two appetite- regulating hormones. Leptin is associated with appetite suppression and ghrelin is an appetite stimulant that is thought to play a role in long-term regulation of body weight. During sleep deprivation, leptin levels fall and ghrelin levels rise.

Adults who are trying to maintain a healthy weight after weight loss are advised to get even more physical activity than the 30 min/d (described above) that is currently recommended; the US Department of Agriculture has recommended at least 60 min/d to manage weight. Weight management leading to a slow, steady weight loss is more beneficial that a pattern of weight cycling, which actually contributes to an elevated risk of mortality.

The basal metabolic rate decreases with age, in parallel with a decline in lean body mass, and body fat increases proportionally. Thus, in order to most readily achieve normalization of body weight and body composition, an energy-sufficient (but not excessive) diet should be combined with a program of regular physical activity to permit maintenance of basal metabolic rate.

The prevalence of injection drug use among older adults is unknown. Injection drug users typically initiate injection drug use during late adolescence (younger than age 21); however, a sizable subgroup begins injecting during early and late adulthood. Persons with a history of recreational drug use on only one or a few occasions are unlikely to self- identify; thus, clinicians should probe for such a pattern of usage.

Noninjection drug use (crack smokers, methamphetamine, intranasal heroin, or cocaine, etc.) contributes to development of gastroduodenal ulcers, chest pain and myocardial infarction, and increased risk of death. Higher levels of drug involvement also were associated with increased age-adjusted

mortality. The normalization of recreation drug use through marijuana legalization laws and the aging of the baby boomer generation, which has had greater experience with recreational drugs, are widely expected to increase the rates of recreational drug use in older adults.

Prescription drug misuse is poorly described in the medical literature but is currently a more prevalent problem than illicit drug use among older adults. Misuse of prescription medications may be related to insomnia, chronic pain, depression, and anxiety. The potential misuse of benzodiazepines is well recognized and has led to prescribing recommendations that suggest only short-term use and use only for intended indications. Amphetamine-like stimulants have abuse potential, but addiction to these drugs is seldom documented. Other medications that are often misused are sedative hypnotics, opioid analgesics, and barbiturates. Chronic use of such agents may lead to physical dependency and the development of withdrawal symptoms with attempts to discontinue use. Treatment may require detoxification followed by rehabilitation.

The majority of older adults residing in nursing homes have significant physical impairments, with over half requiring assistance in toileting, bathing, and/or transferring. Nearly half have a diagnosis of Alzheimer disease or other dementias, and more than half receive 9 or more routine medications. Consequently, preventive medical interventions should carefully consider (1) the time-to-benefit of each intervention as life expectancy may be limited, (2) short-term harms, and (3) how to prioritize competing medical needs. In this respect, the framework for preventive care in most nursing home residents is analogous to the framework for preventive care for palliative care patients with serious, life-limiting illness (eg, cancer, end-organ failure, or neurodegenerative diseases).

In these populations, clinicians should consider early on whether screening tests might require downstream invasive testing for positive tests, and if individuals would be willing and able to undergo such testing.

burdensome to patients already managing multiple medical conditions. Moreover, individuals with dementia and their family members require careful counseling and consent prior to testing. Medications for asymptomatic conditions should be regularly reevaluated to determine if deprescribing is appropriate (eg, de-intensifying glycemic control).

Behavioral counseling might involve managing expectations about reasonable goals, for example, with maintaining moderate physical activity or community engagement. Moreover, serious illness and multimorbidity may themselves lead to unavoidable changes in health behaviors. For example, dementia can lead to the loss of interest in eating and malnutrition, and so families should be provided anticipatory guidance on what can be “prevented” and what may be expected as part of the disease trajectory. In general, eliciting patient and family values and preferences can help clinicians align available preventive interventions with the goals of individual patients.

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Terry Fulmer, Maryama Diaw, Chaoli Zhang, Jinghan Zhang, Wendy Huang, Amy Berman, Tara Asokan, Kedar S. Mate, Leslie Pelton

With an unprecedented acceleration of the population living successfully into old age, the reimagining of the health care system is an imminent and compelling responsibility. There is an urgency to reform the fragmented delivery of health care to improve continuity across care systems as well as to adopt a unifying framework that is readily understood and implemented universally by providers and patients alike. Patients and families want respect and compassion, to learn about what to expect about their health and health care, and to be able to have a strong sense of trust in their caregivers and institutions.

Reliable team approaches are essential, given the complexity of our systems. Interprofessional team (IPT) care is essential to providing effective care for older adults with multiple conditions and functional decline.

Research has demonstrated that IPT care is associated with enhanced functional and cognitive status, reduced depression, and improved subjective well-being. IPT care has also been shown to reduce hospital readmissions and outpatient service use. Specialized IPTs focusing on specific conditions

such as congestive heart failure, stroke, myocardial infarction, or dementia have also demonstrated improved patient outcomes in older adults.

The current and projected health care workforce shortage, coupled with the aging of the population, mandate that care models be measurably efficient and effective. The increasing number of frail older adults with complex needs demands widespread adoption of geriatric IPTs. In this chapter, the Age-Friendly Health Systems (AFHS) movement, coupled with the essential elements of team-based care, are discussed as a way forward and new standard of care.

Key Clinical Points

Team-based geriatric care is critical to the delivery of comprehensive, coordinated health care to older adults, their families, and caregivers.
The Age-Friendly Health Systems movement is an evidence- based approach to care that when implemented reliably, improves quality, improves health, and reduces costs.
The 4Ms set, What Matters, Mentation, Medications, and Mobility, provides a framework that addresses the multiple intersections of each of the 4Ms.

High-Functioning Teams as a Prerequisite to AFHS and 4Ms Care Through the collaborative efforts of The John A. Hartford Foundation (JAHF) and the Institute for Healthcare Improvement (IHI), in partnership with the American Hospital Association (AHA) and the Catholic Health

Association of the United States, the AFHS initiative has had strong momentum (Figure 12-1). Already established in over 2,600 sites of care across the country, this progress indicates a willingness to adopt the 4Ms model and study the impact. The AFHS movement has the goal of reaching 25% of hospitals and primary care settings by 2025.

The IHI Triple Aim is the basis for the AFHS approach that focuses on improving the patient experience of care (including quality and satisfaction), improving the health of populations; and reducing the per capita cost of health care. The four evidence-based facets of care known as the 4Ms (What Matters, Medication, Mentation, and Mobility) have evolved from the tenets of the Triple Aim.

However, achieving specific health outcomes of at-risk populations also requires the combined skills of a wide range of professionals operating as a team. Team members possess extensive professional knowledge of their individual discipline but often have limited knowledge of other disciplines on the team. Beyond varied technical knowledge among team members, teams may be characterized by different values across professional disciplines. These differences are becoming less pronounced with the evolution of IPTs in most health care settings and with many populations. The 4Ms set, described in this chapter, provides every team member with the

same elements of care that each member will see through their own clinical lens, which helps ensure a holistic approach to the care plan. The Veterans Health Administration characterizes high-functioning teams as those that excel in both function (effectiveness) and relationships (engagement).

Effectiveness refers to the team’s purpose and methods, role clarity, communication, awareness, and responsiveness (eg, how the team uses and shares information). Engagement is a function of the level of civility, respect, psychological safety, and cohesiveness of the team. There is a balance in the nature and function of relationships on the team. Limited attention to developing professional relationships may impede the development of trust and collaboration, which can impair team function. However, excess focus on cohesion and collaboration may limit communication and prevent different opinions from being openly discussed.

Professional disciplines vary significantly in how they characterize problems and their etiology. For instance, more medically oriented disciplines may focus on conducting diagnostic tests and explaining findings in biological terms, whereas the social sciences (eg, psychology, social work) may emphasize psychosocial issues and consequences. In addition to differences in understanding and formulating plans of care, team members of different disciplines vary substantially in the nature of treatments they typically prescribe and in the length and frequency of patient visits. These differences in perspectives and approaches can be overcome when a 4Ms approach is used and all team member input is recognized and respected.

While teams work toward a patient-centered outcome, individual team member competency remains essential. Teamwork requires discipline- specific clinical knowledge and skills and methods that allow all members to be heard—involving processes to communicate clearly, meet routinely, and understand the individual clinician’s role in the care plan. Older adults with multiple chronic conditions or advanced illnesses stand to benefit most from a shift from a disease-centered care delivery system to the AFHS model of care.

An AFHS means being able to reliably provide a set of four elements of evidence-based, high-quality care, known as the 4Ms: What Matters, Medication, Mentation, and Mobility, shown in Figure 12-2. When the four elements are consistently implemented together as a set, they allow for a shift

in focus from disease to function that accelerates the ability to better serve the needs and preferences of older adults. The 4Ms make the care of older adults more manageable and reduce the cognitive burden on care teams that is often felt in the delivery of complex clinical care. Focus is placed on the overall wellness and capabilities of older patients rather than siloed diagnostic assessments that often overlap and can create contradictions in care planning.

FIGURE 12-2. 4Ms interaction. (An initiative of The John A. Hartford Foundation and the Institute for Healthcare Improvement [IHI] in partnership with the American Hospital Association [AHA] and the Catholic Health Association of the United States [CHA].)

This approach guides the care of older adults irrespective of the location of care, and the 4Ms approach is most impactful when the team communicates progress in the 4Ms at every handoff. There is a strong evidence base for each of the 4Ms that is leading to improvement in health systems and creating sustainable change.

What Matters is what truly drives patient-centered care and is essential to addressing the unique needs of older adults, eliminating harm, and maximizing the efficiency of health care delivery. What Matters supports the values and activities that each person wishes to prioritize. The AFHS initiative defines What Matters as knowing and aligning care with each older

adult’s specific health outcome goals and care preferences, including, but not limited to, end-of-life care, across settings of care.

Beyond the scope of disease-specific outcomes and survival statistics, an age-friendly infrastructure considers What Matters and consistently documents the same care priorities among health care providers, families, and patients. Shared decision-making, which directly involves the patient in the care conversation, has been shown to increase trust and satisfaction within health care systems and with care delivery, while also reducing fragmentation among clinicians and supernumerary demands on clinicians. A network-wide clinical trial conducted by a team of researchers at Yale has shown this through the utilization and analyses of patient preference data collected from three surveys, including the Treatment Burden Questionnaire (TBQ). Older patients who were given the opportunity to express what mattered to them, compared to those who received usual, unprioritized care, were more likely to have unnecessary medications deprescribed and had fewer diagnostic tests, referrals, and procedures. After being explicitly asked to identify their values-based health priorities and speaking to their primary care physicians concerning these priorities, TBQ measurements collectively demonstrated a 5-point decrease in treatment burden score after a 6-month follow-up period, compared to baseline. As connoted in the 4Ms framework, health care that prioritizes older patients’ health preferences can significantly decrease clinical harm and simultaneously have a positive impact on patient satisfaction. Table 12-1 provides a checklist for culturally appropriate “What Matters” conversations.

TABLE 12-1 ¦ CHECKLIST FOR CULTURALLY APPROPRIATE “WHAT MATTERS” CONVERSATIONS

The topic most sensitive to older adults’ wishes and priorities is decision making related to end-of-life care and serious illness. In efforts to honor the bioethical principles of autonomy and informed consent, the development of advance care planning (ACP) has been a critical aspect of What Matters in the 4Ms framework. ACP is the process of intentional solicitation of decisions from patients and families regarding their preferences for health care. If nurses, physicians, and other health care professionals ask and document decisions based on older patients’ health priorities, goals, and preferences, health systems can honor What Matters to older adults and avert potentially unwanted care. In a randomized controlled trial (RCT) conducted at a large university hospital, patients receiving formal, coordinated ACP from trained facilitators were found to have their end-of-life wishes known and respected significantly more than the control group, indicating increased patient and family satisfaction with the care provided in discharge questionnaires. Patients saw the benefits of ACP to include the informal communication of future wishes, preparation for end-of- life care and death, avoidance of prolongation of dying, strengthening of personal relationships, and relieving burdens placed on family.

Documenting and incorporating What Matters information is a reliable, timely nonpharmacologic intervention that, when deployed, benefits the older adult involved and participating health systems. It enables the leveraging of interdisciplinary team resources and serves to stand as a quantifiable process measure. Beneficial care in congruence with reductions in the incidence and

duration of unwanted and avoidable hospital stays, procedures, emergency department visits, medications, etc., stand to improve quality and efficiency across the board for older adults and health systems alike.

Managing medications to ensure that they are only prescribed when necessary, are financially accessible, and well-understood and safely adhered to is central to the health of older adults who need them.

Deprescribing may be even more important. In 2015, an estimated 29% of Medicare beneficiaries filled a prescription for at least one medication included in the 2015 American Geriatrics Society Beers Criteria list of drugs to avoid in older adults. The risk of dangerous side effects in older adults is high. The 4Ms framework, and medication management specifically, includes attention to age-friendly medications that do not interfere with What Matters to an older adult, Mobility, or Mentation across settings of care.

IHI’s Guide to Using the 4Ms in the Care of Older Adults emphasizes the importance of proper prescription protocol for older adults. Clinicians need to be alert to inappropriate medications and polypharmacy (multiple medications). In research assessing polypharmacy’s impact on delirium, polypharmacy was found to be a risk factor for delirium in older patients after emergency admission. One measure that health systems must prioritize is safely deprescribing or abstaining from prescribing high-risk medications.

An evidence-based approach to limiting the over-prescription of high- risk medications and reducing the negative impacts of polypharmacy is the use of computerized decision support (CDS) systems. The Screening Tool of Older Person’s potentially inappropriate Prescriptions (STOPP) and the Screening Tool of Alert doctors to the Right Treatment (START) have been used across systems to alert providers of potential problems with medications. Risks associated with prescribing a medication may outweigh the potential benefits. STOPP/START has been found to be beneficial in addressing inappropriate prescribing in older adults. When used, the criteria significantly improved prescribing methods, resulting in a lower prevalence of falls and all-cause mortality.

The impact of CDS systems on potentially inappropriate prescriptions (PIP) and potential drug-drug interactions has been positive. Avoiding drug- drug interactions is a critical aspect of providing medication services to older populations due to increased comorbidities in older adults.

The 4Ms framework ensures that medications are continuously reviewed, that high-risk medications are avoided, dose adjusted, or deprescribed when clinically appropriate, to improve the probability that medications are safe, appropriate, and well understood by the older adult and their caregivers. It should be noted that primary care physicians express a lack of time, poor awareness of the harms of medications, and fear of withdrawal symptoms or patient criticism as barriers to deprescribing. A team approach, where all members are empowered to do a medication assessment can help alleviate these concerns on the part of any one team member. Clinicians across the board must be proactive in deprescribing and improving medication management for older adults.

In a study designed to showcase the role of all health care settings in decreasing the negative impacts of polypharmacy through deprescribing, pharmacists were placed at the forefront of providing patients a role in the decision-making process to deprescribe. Pharmacists in the intervention arm were given educational brochures to distribute to both patients and prescribers, while those in the control group provided the usual standard of care. Those in the intervention arm experienced a discontinuation of medication in almost half the cases, compared to 39% of cases for those in the control group.

The benefits of desprescribing are also evident when complex medication plans contribute to poor medication adherence. The primary barriers affecting medication adherence have been characterized as patient factors, medication factors, prescriber factors, system-based factors, and other factors. Each play a key role in either enhancing or complicating the medication protocols/schedules found to negatively affect medication adherence. In alignment with the 4Ms framework, medication plans need to be person-centered and simplified whenever possible for all involved. Cost- related medication nonadherence in older adults is also a serious problem and can lead to skipped or reduced doses due to costs, as noted by an analysis of the 2017 National Health Interview Survey (NHIS). Knowing that approximately 20% of older adults take 10 drugs or more, eliminating medication overload can improve the outcomes of care.

Assessment and care planning for optimal mentation, which includes mood and memory, helps prevent, identify, treat, and manage dementia, delirium,

and depression across all settings of care. Dementia, delirium, and depression are covered in detail in other chapters in this text (see Chapters 58, 59, and 65, respectively). When health care providers reliably assess and create appropriate care plans for these three common conditions, qualitative and quantitative gains are evident for patients and health systems alike.

Dementia is more prevalent with advanced age but should not be conflated with normal aging. It is a neurodegenerative syndrome characterized by accelerated cognitive decline that interferes with activities of daily living. Dementia can compromise the independence of older adults and increase caregiving needs. Person-centered care (PCC) for older adults with dementia is a sociopsychological intervention that has been proven to significantly improve the overall quality of life and neuropsychiatric symptoms (NPS) when applied directly to clinical practice and care settings. Table 12-2 highlights the philosophy of PCC, which revolves around six fundamentals in line with the Alzheimer’s Association Dementia Care Practice Recommendations. A meta-analysis and systematic review drawing results from several RCTs favored PCC interventions by reducing agitation and decreasing the severity.

TABLE 12-2 ¦ PRACTICE RECOMMENDATIONS FOR PERSON- CENTERED CARE FOR PEOPLE LIVING WITH DEMENTIA

In the fifth edition of the American Psychological Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5), delirium is clinically classified as a “disturbance in attention (ie, reduced ability to direct, focus, sustain, and shift attention) and awareness (reduced orientation to the environment)…[that] develops over a short period of time (usually hours to a few days), represents an acute change from baseline attention and awareness, and tends to fluctuate in severity during the course of the day.” It is especially important to note that mental status change in delirium appears as a direct psychological consequence of another etiology, especially preexisting medical conditions (excluding dementia) and medication toxicity. While its underlying pathophysiologic mechanisms can be elusive, delirium is a dangerous clinical condition. In hospitalized patients, an episode of delirium leads to detrimental sequelae, including major complications after surgeries, prolonged length-of-stay, loss of functional autonomy, decreased cognitive abilities, and increased mortality. These effects contribute to rising costs for health systems. In all settings of care including care by family members in the home, delirium poses a frightening and dangerous situation.

every care provider can detect potential signs and symptoms of delirium and get the requisite care for the older adult in a timely manner.

The Tailored, Family-Involved Hospital Elder Life Program (t-HELP), which centers on family involvement for those older adults at risk for experiencing delirium, has been shown to improve detection and prompt early treatment. Postoperative delirium (POD) is associated with increased morbidity and mortality, and can be reduced or prevented. The improved mental and physical recovery after surgery and shorter hospitalizations are indicative of t-HELP’s efficacy, which harbors the potential to save health care systems untold millions of dollars. In AFHS, the use of evidence-based protocols to assess and attend to modifiable risk factors of delirium (eg, mobilization, orientation, sensory adaptation, social interaction, assistance with meals and hydration, etc.) help ensure Triple Aim care. Hartford Hospital is an example of an organization that has made a commitment to rigorous delirium screening in the context of 4Ms care and is discussed in a later case study.

Depression is a potentially life-threatening condition for older adults and is encompassed in the 4Ms framework as a part of the Mentation assessment. Prevalence of depression is estimated to range from 10% to 30% (see Chapter 65). There are several types of depression, and the most common include: major depression with severe symptoms that interfere with the ability to work, sleep, concentrate, eat, and enjoy life; persistent depressive disorder, also known as dysthymia with symptoms that are less severe than those of major depression, but last a long time (at least 2 years); and minor depression with symptoms that are less severe and shorter in length than those of major depression and dysthymia. In a 4Ms assessment of Mentation, depression screens are important to determine if depression is present and if so, making an appropriate referral to a provider who can follow up with a treatment plan. The older adult may also describe a grief event that is at the root of the depression and here as well, follow-up is important for the well- being of the older adult. Screening for depression is recommended annually or when symptoms arise. Evidence supports using one of the following four screening tools: Patient Health Questionnaire-2 (PHQ-2), Patient Health Questionnaire-9 (PHQ-9), Geriatric Depression Scale (GDS), and Geriatric Depression Scale - short form (GDS - short form).

The positive effects of physical activity on mobility from improved muscle strength and balance as well as the protective effects against falling are well- documented. As older adults age, having the ability to move independently and safely plays an increasingly important role in how an older adult’s quality of life is defined. Living with any disease puts additional burden on an older person’s mobility. For example, diabetes mellitus increases the risk of falls in older adults, and clinicians must be attentive to the likelihood of older adults with diabetes needing education related to this risk and offer a mobility program that can be guided by physical therapy. Most chronic conditions play a role in reducing physical, cognitive, and social functioning. The 4Ms approach is especially effective in addressing function in a holistic manner that is readily understood by older adults and their families.

Medication, visual deficits, cognitive and mood impairment, and environmental hazards can all limit mobility. For instance, use of benzodiazepines, which are hypnotic sedatives prescribed to treat conditions such as anxiety and insomnia, correlates to an increased risk of falls in older adults and should be avoided. Preventative measures for maintaining mobility include regular vision and hearing examinations, continuous assessment of medications and provision of exercise protocols to increase balance, gait, and strength are recommended. Encouraging exercise in older adults is a recognized method for increasing the mobility of older adults and is recommended to be incorporated in their care. The role of exercise in decreasing the risks of falls is well-documented (see Chapter 43). However, as with any age group, motivation for maintaining exercise regimens can be a challenge. AFHS approaches strive to create person-centered, context- dependent care plans such as group exercise classes for some or caregiver education and strategies to ensure Mobility for others.

The value of becoming an AFHS and implementing the 4Ms framework (also referred to as financial benefits) is detailed in IHI’s “The Business Case for Becoming an Age-Friendly Health System.” When implemented properly, AFHS can ultimately lead to reduced hospital length of stay and fewer hospital readmissions.

Annual Wellness Visits (AWV), covered by Medicare Part B since 2016, are designed to engage older adults in What Matters conversations as a part of the annual benefit. An AFHS approach can improve value by

systematically using the AWV to review the 4Ms. In fact, fee-for-service claims data from 2013 to 2018 demonstrated that AWV users had a reduction in Medicare spending over 12 months. St. Vincent Medical Group (Indianapolis, IN), an institution in the Ascension system, which represents one of the five pioneering health systems that spearheaded the AFHS initiative, also demonstrated value. When revenue from ACP and associated gross benefits from AWV are considered, St. Vincent showed an annual net income of nearly $3.6 million. When asking What Matters, clinical teams enhance value for patients and families.

Nonfatal falls account for almost 99% of the estimated health care costs for fatal and nonfatal falls, which amounted to a total of $50 billion in 2018. This number for just nonfatal falls was estimated at $38 billion in 2013.

Beyond the key purpose of leveraging the 4Ms framework to improve quality of care, creating AFHS and ensuring that older adults can afford their medications and avoid medication overload can result in long-term savings that will benefit all sectors.

Case Studie s At Hartford Hospital in Connecticut, age-friendly initiatives have led to resounding impacts in value and care. The ADAPT (Actions to enhance Delirium Assessment Prevention and Treatment) program was started in 2012 as an interprofessional team effort across various disciplines and departments, with support from the hospital administration and vital resource allocation for positive reinforcement and opportunities for improvement. A delirium care pathway was developed to ensure that delirium prevention, treatment, and management remained an interprofessional priority throughout the length of an older patient’s stay and transitions. This included the implementation of delirium screenings three times a day, in addition to an initial screen. Adjunct support was provided through various means, from volunteer programs to therapeutic activities focusing on mobilization, nutrition, sleep/rest, and cognitive connection. A registry was also created for gathering data and analyzing quality outcome measures.

As seen in Table 12-3, delirium was shown to have serious consequences leading to poorer health outcomes, with the length of hospital stay averaging 4 days and $8,900 for those without delirium, and 12 days and

$31,284 for those with delirium. Seventy percent of those without delirium were discharged home, compared to only 30% for those with delirium. And while mortality was less than 1% for patients without delirium, it was 10%

for patients with delirium. The implementation of the ADAPT program led to decreased hospital stays for delirium patients (16–10.6 days) and reduced delirium attributable days. This resulted in annual savings averaging $6.5 million from 2012 to 2019. Hartford Health care has now taken steps to scale up the program, with potential expansion to other care settings (post-acute and home care) and a focus on population health in primary care clinics for underserved community-dwelling older adults.

TABLE 12-3 ¦ HARTFORD HOSPITAL PER-PATIENT COSTS ASSOCIATED WITH DELIRIUMA

Another example that has exhibited beneficial results has been Providence St. Joseph Health in Oregon, one of the original five locations chosen to take place in the development of AFHS. Beginning in 2017, changes in care included coordinating fall-risk screening and management, developing an outpatient mobility program, creating a dementia care pathway, educating clinical staff on polypharmacy and high-risk medication, and utilizing a What Matters Discussion Guide to direct communication. To implement these changes on a greater scale, Providence St. Joseph Health formed the Geriatric Mini-Fellowship in 2018, training providers at 12 primary care clinics.

The training resulted in a myriad of improved outcomes at these clinics. In terms of mobility, the move toward more comprehensive and coordinated preventative measures and care led to a doubling in screening for fall risk and cognitive impairment and quadrupling of fall-risk interventions being administered. Older patients were also more likely to engage in What Matters conversations with their providers, and the prescribing of high-risk

medication decreased by 3% when seen by a fellow. Finally, these clinics where providers received training on AFHS experienced a reduction of 2% to 7% in hospitalizations for patients.

In a world where populations are aging more rapidly than ever before, the need to shape health systems to deliver quality care to older adults becomes an increasingly pressing health priority. The Triple Aim clearly points to the need for AFHS and 4Ms care, which improves the health and well-being of older adults through ensuring that families, caregivers, and health care provider teams all work synergistically. The 4Ms framework is driven by patient-centered care and prioritizes the older adult’s preferences to simultaneously include medication management, prevention and treatment of dementia, delirium, and depression, and safe physical activity. The cost- effective practices and teaming of this approach can guide a higher quality of care for an aging population and significantly reduce unnecessary hospitalizations, saving health systems billions in health care spending. The evidence-based benefits of 4Ms care are clear and thus, emphasize the need for AFHS across health care settings.

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Hidenori Arai, Jacqueline C. T. Close, Len Gray, Finbarr C. Martin, Luis Miguel Gutierrez Robledo, Stephanie Studenski

Throughout the world, the aged proportion of the population is increasing. The number of older persons has tripled over the past 50 years and will more than triple again over the next 50 years. In contrast with the slow process of population aging experienced by the more developed countries, population aging in most of the less developed countries is taking place in a much shorter time period and is occurring in a larger population. Such rapid growth will require far-reaching economic and social adjustments in most countries. Effective and efficient health care for the chronic health problems facing this growing population of older adults will be a daunting challenge for all countries.

Notwithstanding some heterogeneity, life expectancy is increasing across the globe. In most industrialized countries, this increase in life expectancy has mostly occurred over the past century. However, in the most recent decades, its pace has progressed at an unprecedented speed, reaching estimates far beyond those predicted by most international organizations such as the United Nations. The increase in life expectancy has resulted in an increased proportion of individuals reaching the eighth and ninth decades of life. Aged individuals are consistently found to be the fastest growing segment of the population, and the rate of growth is more rapid in developing compared to developed countries (Figure 13-1). As life expectancy increases, there has

been a wide decline in fertility rates, resulting in a decreasing dependency ratio: a smaller number of working age adults for each aged person. This trend has great and challenging implications for national approaches to support services for older adults. Since wealth and resources vary greatly across countries, priorities for health and social services vary as well. Many developing countries previously focused on infectious diseases and

maternal-child health, but as they too face rapidly aging populations, they are now confronting the same challenges to health care as have developed countries in recent decades.

FIGURE 13-1. Growth over time in the aged population in developed and developing countries. All numbers are millions of people. (Reproduced with permission from US Census Bureau, Current Population Reports: 65+ in the United States.)

In most countries, there are still not enough geriatricians to serve the special needs of vulnerable older people.

As age increases, there is a progressive, exponential increase in the occurrence of most chronic, degenerative, and progressive diseases, including cardiovascular disease, cancer, chronic obstructive pulmonary disease, dementia, and other degenerative conditions (see Chapter 2).

Furthermore, there is an increase in the co-occurrence of these diseases, resulting in multimorbidity (see Chapter 41).

Health care systems around the world have been based on a disease model. Diagnosis and treatment focuses on eliminating or ameliorating the underlying pathology; health outcomes are determined by the disease. Also, functional impairment and quality of life are assumed to be improved by treating the “causative” disease. The disease model resulted in the creation of health systems centered on acute care hospitals and disease (or organ)- based specialists. This model informed the way we developed and accrued knowledge. Consequently, physicians and health personnel are now facing a “new” and less familiar type of patient who presents with an array of concomitant clinical conditions. These combinations of conditions result in varying degrees of functional deficits, cognitive deterioration, nutritional problems, and geriatric syndromes (delirium, falls, incontinence), often in the face of inadequate social support and financial resources.

This “new” older patient presents a degree of complexity not previously considered by the traditional understanding of medicine and its role. The traditionally envisioned health care system, whether operating under universal coverage or private mechanisms, is challenged by this complex patient.

The response to the challenge of the complex older patient has been heterogeneous around the world; differences in resource availability and economic and cultural issues resulted in different organizations of health care systems. In addition, the methodological approaches adopted by systems to evaluate the needs of such complex patients have been highly variable and not standardized. In particular, the organization of services to care for

geriatric patients, including geriatric assessment and management, remains highly variable. This variation is seen among nurses, physicians, therapists, nursing homes, home care services, and health systems.

Geriatric Medicine emerged as a medical specialty in the mid-twentieth century—somewhat later than the majority of organ- and procedure-oriented specialties. This emergence was initially inspired by the realization that among older people living in institutions, there was a substantial prevalence of diagnoses and functional impairments that could be resolved by careful diagnostic review and implementation of rehabilitation techniques. However, ultimately Geriatric Medicine approaches were found relevant to all older people, regardless of the care setting. In addition, there was a growing body of evidence that disease presentations and responses to treatment may differ among very old people compared to middle-aged adults. As this awareness was applied to hospitalized patients and older people living in the community, there was an appreciation that the social and physical context of older people also influences functional status and outcomes.

Despite a growing body of knowledge pertaining to illness in old age and a strong evidence base for its practice, the specialty has not been uniformly adopted across, or even within, nations. Moreover, even where it is established, practice is often restricted to particular settings—hospitals, nursing homes, or ambulatory clinics. This may be a product of the overall configuration of specialty practice, funding and financial incentives, lack of leadership, or perceived lack of need at professional or government levels.

In many jurisdictions, geriatric medical specialists are only present in large academic or metropolitan settings. In some developing nations, the discipline may not exist at all.

Within hospitals, a variety of practice models have emerged. Acute geriatric units, supervised by geriatricians, may admit acutely ill patients directly from the emergency department or community. Alternatively (or in addition), Geriatric Medicine may be restricted to post-acute units, where patients are transferred after initial assessment and triaging in an acute unit. These post-acute services may be based on a separate subacute ward within an acute hospital, or co-located within a long-term care facility.

Outside of hospitals, Geriatric Medicine may have a presence in long- term care, where geriatricians might act as the primary physician workforce.

In other jurisdictions, they may act primarily as specialists, consulting for patients who are referred by primary care practitioners, with or without any special training in care of older people.

In most jurisdictions, a shortage of geriatricians is perceived. Even where the specialty is firmly entrenched and available in a particular setting, there may be inadequate availability in other care settings. Situations where a geriatrician is available to consult about patients across the entire care spectrum are probably relatively rare.

Geriatric medical practice and its availability should reflect the needs of the oldest members of a society. As such, with near-universal population aging, it would be reasonable to anticipate that Geriatric Medicine should emerge progressively throughout the present century.

Consistent assessments can provide a mechanism to draw comparisons among like services in different nations and, if configured appropriately, even across care settings within and among nations. The interRAI suite of assessment systems was designed to meet this requirement. It has been used to draw comparisons across nations and jurisdictions within them. Two important multination research projects in Europe in home care and long- term care have been influential in identifying different patterns of service use, clinical outcomes, medication use, and quality issues which, in turn, influenced policy in several nations. Data extracted from large databases (in some cases millions of assessments) enabled similar examinations among nations and jurisdictions and organizations within them. These systems have been adopted at an organizational level (eg, a nursing home) or by state or nations (eg, the interRAI Home Care and Long-Term Care systems in New Zealand). Several nations and states adopted multiple suite instruments (eg, Belgium and Ontario, Canada). These early suite adopters are exploring the utility of multiple compatible instruments to facilitate cross-setting continuity of care (a clinical benefit) and comparisons of caseloads across settings (a policy benefit).

In this chapter, we provide an overview of geriatrics training and certification, clinical practice, and institutional support in 63 countries.

While many countries have active aging research programs, this chapter does not address those. We are exceptionally grateful for the information provided by national leaders from each country through an online survey. Among the 63 countries, based on the current classification of countries by the World Bank, 42 were high income (national income per capita >US$ 12,536 in 2019) of a total of 59, 17 were upper middle income (of a total of 55), and 4 were lower middle income, of a total of 44. There were no respondents from low-income countries, of a total of 28. There are a few countries, mainly very small, that were not classified by WHO.

All respondents provided their best estimates about geriatrics in their countries; however, given the great variability in how health care is organized and geriatrics is defined, some of the information is likely to be inexact. We regret that we were not able to identify national leaders for every country and hope to include others in future versions of the chapter.

Geriatrics training and certification vary among responding countries. Some countries with early emerging roles for geriatrics specialists largely import trained geriatric professionals from other countries. Nearly 90% of the countries surveyed reported the presence of formal training programs in geriatrics (Figure 13-2A). However, the timing and requirements vary considerably. For example, many countries train physicians in geriatrics through individual certified training programs offering 1 to 4 years of advanced geriatrics training after residency in Internal Medicine or Family Medicine, or combined Internal Medicine and geriatrics training lasting 4 to 5 years after medical school (Figure 13-2B). Many of these programs are operated independently by hospitals and academic health systems. Other countries have a single national training program which has been implemented in multiple health care systems. Many countries offer a national certification examination, while others provide certification through national societies using a range of metrics (Figure 13-2C). Some countries do not offer a formal path to certification, so the definition of a geriatrician can depend on national or regional standards. Many countries offer educational programs regarding care of older people to a wide range of trainees: some

occur during professional training while others are designed for practicing health care providers. For the most part, this chapter focuses on formally trained geriatrics specialists.

FIGURE 13-2. A. Does your country require a defined period in a certified training program to be qualified as a geriatrician? B. Types of training programs in geriatric medicine in 63

countries. Other includes some programs that are transitioning between types of training or are starting a formal training program, some geriatric training programs are longer than 2 years, and some are 18 months after Internal Medicine. FM, Family Medicine, IM, Internal Medicine. C. My country requires a successful score on a standardized certification examination to be qualified as a geriatrician.

In some countries, formal training and certification is offered to health professionals other than physicians. Most common is geriatrics specialization for nurses, followed by physical and occupational therapists and social workers.

While definitions vary for who is a geriatrician, our national respondents reported a very wide range of numbers of geriatricians per 100,000 persons age 65 or older (Table 13-1). A proposed criterion from the Royal College of Physicians (RCP) is that there should be 2 geriatricians for every 100,000 persons age 75 or older. This estimate is based on a consultative, not primary care, model of medical care, so it is difficult to relate the RCP estimate to the findings of our survey. Some countries report national efforts to increase the number of trained geriatricians, but others do not.

TABLE 13-1 ¦ TRAINING AND CERTIFICATION IN GERIATRICS IN DIFFERENT COUNTRIES

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Geriatricians practice in many settings (Figure 13-3A). The most common setting is the hospital, followed by outpatient clinics. Geriatricians tend to work in larger hospitals, academic centers, and cities. In many countries, medical aspects of long-term care are managed by general practitioners, not geriatricians. Practice varies widely within countries; many only have special geriatric services in a few health care settings, while other countries have somewhat greater geographical spread of services. Geriatricians practicing in hospitals usually work on dedicated geriatrics wards (Figure 13-3B), but also in collaboration and consultation with many other services, most commonly orthopedics, oncology, and emergency wards (Figure 13- 3C). Similarly, general geriatrics is the most common outpatient service, but many other specific services are offered, including treatment for dementia, falls/balance/mobility, and incontinence (Figure 13-4A). Over half of respondents reported that geriatricians in their country provide home services such as home visits or home care coordination. Similarly, over half of respondents reported that geriatricians worked in rehabilitation settings, more often in acute hospital compared to long-term care settings.

FIGURE 13-3. A. Where do geriatricians practice in your country? Respondents can select multiple sites. Other includes public health, regional variability in sites of practice, emergency room, mobile teams, life care communities, and PACE-type programs. B. Are there designated hospital beds for geriatrics in your country? C. Are there formally established collaborative teams with geriatrics on specialty hospital services in your country? Respondents can choose more than one. Other includes general and specialties of surgery, neurology, stroke, dermatology, psychiatry, rehabilitation, palliative care, COVID-19, and CGA screening for 75+. CGA, Comprehensive geriatric assessment; PACE, Program of All-Inclusive care of the Elderly.

Some geriatricians are salaried in almost all participating countries, while about half of countries report that geriatricians also receive individual payment for services (Figure 13-4B). Salaries come from governments, hospitals, and other institutions. Payments for services come from health insurance and directly from private payers. Somewhat less than half of countries report that geriatrician assessment is sometimes required for paid services such as long-term or home care (Figure 13-4C).

FIGURE 13-4. A. Types of geriatric outpatient services in 63 countries. Other includes frailty, polypharmacy, oncogeriatrics, geropsychiatry, osteoporosis, preoperation, movement disorders, and day hospital. B. How are geriatricians paid in your country? C. Does your country ever require a geriatrician assessment for eligibility for services or other benefits?

Quite a few countries have evolving policies and practices related to geriatrics. For example, in Israel, geriatricians can be paid by the Social Security System to assess people age 90 or older for eligibility for home services for those with functional impairment. The United Kingdom has had a National Health Service framework for aging services and requires specialist geriatricians to participate in care for all hip fracture patients.

Japan provides incentives for comprehensive geriatric assessment on hospital admission and for evaluating and deprescribing for polypharmacy. In Germany, geriatricians are obligatory providers in the care of hip fracture patients age 70 or older. In Australia, the Royal Commission is requesting an increased role for geriatricians in long-term care. Australia is also working to increase availability of geriatricians for indigenous older people and those in correctional settings. In Norway, there is an expectation that all large acute care hospitals have geriatricians. In Malta, geriatricians mostly work outside acute care, particularly in specialized post-acute/rehabilitation settings; they assess acute care patients for eligibility for transfer to the post-acute setting. In Turkey, there is an aim to increase the number of geriatricians, who have an obligatory service requirement to work in areas determined to have an unmet need. In France, nursing home care is provided by general physicians with specific training in geriatrics. North Macedonia is in the process of organizing a geriatrics specialty.

More broadly, several countries report other developments in the coordination and management of care for older people. New Zealand uses a national approach for assessment based on the interRAI tool. Taiwan is using an Integrated Care for Older People (ICOPE) assessment for screening older people. The government of Thailand has set a national agenda on aging and created the Association of Southeast Asian Nations Center on Active Aging and Innovation. Nicaragua has created a program Todos con Vos for persons age 60 or older. Nicaragua also has a program in collaboration with Social Security for retired people that partners with Public Health to provide health care, rehabilitation, and other services. Peru has created laws addressing issues of dementia. Singapore organizes health care among four Regional

Healthcare Systems with a population health focus and efforts to address aging issues. Panama offers a home care system coordinated between the Health and Social Security Systems. Serbia has a national program for health care of older people, and Luxembourg is developing such a national plan.

China offers special geriatrics services in certain hospitals, but is working to extend these services to geriatric wards more widely. Ireland is directing more care to community settings via the Sláintecare program. Belgium is expecting to implement the bel-RAI soon and offers comprehensive assessment through a day clinic. Costa Rica has laws addressing integrated care for older persons. Mexico has a National Institute of Geriatrics which is developing a national action plan for older adults in conjunction with the Ministry of Health. It is promoting the development of Departments of Geriatrics nationwide.

Despite global aging, geriatrics remains a small field almost everywhere, although it is more advanced in developed countries compared to developing ones. There are clear signs that some nations are working to increase the training and availability of geriatricians and geriatric services in their countries. Some countries have integrated geriatricians into program eligibility standards or oversight. Most clearly, there exists a worldwide community of dedicated geriatricians working to improve care for older people in their countries.

We especially recognize the exemplary support provided by Leah Carton of McGraw Hill who developed and managed the web-based survey. Survey participants: Edgar Aguilera Gaona, MD, Paraguay; Vidmantas Alekna, MD, PhD, Lithuania; Hidenori Arai, MD, PhD, Japan; Prasert Assantachai, MD, Thailand; Gülistan Bahat, MD, Prof, Turkey; Melba de la Cruz Barrantes Monge, MD, MsC, Nicaragua; Sylvie Bonin-Guillaume, MD, PhD, France; Carlos Cano, MD, Colombia; Liang-Kung Chen, MD, PhD, Taiwan; A. Mark Clarfield, MD, FRCPC, Israel; Jacqueline Close, MBBS, MD, Australia; Jacqueline Close, MBBS, MD, FRCP, New Zealand; Luis Manuel Cornejo MD, MSc, Panama; A.B. Dey, MD, India; Rebecca Dreher, Medical Doctor, Switzerland; John Ellul, MD, DM, Greece; Predrag Erceg, MD, PhD, Serbia;

Helga Eyjólfsdóttir, MD, PhD, Iceland; Alberto Ferrari, MD, Italy; Pablo Garcia Aguilar, MSc, MD, Guatemala; Deon Greyling, MBChB, M Fam Med, M Med, South Africa; Luis Miguel Gutierrez Robledo, MD, PhD, México; Margarita Henriquez, MD, El Salvador; Susanne Hernes, MD, PhD, Norway; Andrei Ilnitski, MD, PhD, Belarus; José Jauregui, MD, PhD, Argentina; Peter Johnson, MD, Sweden; Shahrul Kamaruzzaman, MBBCh, PhD, Malaysia; Lin Kang, MD, China; Ana Kmaid Riccetto, MD, Uruguay; Helgi Kolk, MD, PhD, Estonia; Yulia Kotovskaya, MD, PhD, DMs, Russia; Adam Lelbach, MD, PhD, Hungary; Jean-Claude Leners, MD, Luxembourg; Wee-Shiong Lim, MBBS, MRCP (UK), MMed (Int Med), MHPEd, AGSF, FAMS, Singapore; Roberto Lourenço, MD, MPH, PhD, Brazil; Lia Marques, MD, Portugal; Nicolás Martínez-Velilla, MD, PhD, Span; Francesco

Mattace- Raso, MD, PhD, Netherlands; Jesús Menéndez Jiménez, MD, MPH, Cuba; Manuel Montero Odasso, MD, PhD, Canada; Fernando Morales- Martínez, MD, Costa Rica; Hanna Öhman, MD, PhD, Finland; Shane O’Hanlon, MB, BCh, BAO, MRCPI, Ireland; Jose F. Parodi, PhD, Perú; Tajana Pavic, MD, PhD, Croatia; Biljana Petreska-Zovic, MD, Macedonia; Karolina Piotrowicz, MD, PhD, Poland; Gabriel-Ioan Prada, MD, PhD, Romania; Rupert Puellen, MD, Germany; Regina Roller-Wirnsberger, MD, MME, Austria; Irma Ruslina Defi, Sp.KFRs(K), Indonesia; Jesper Ryg, MD, PhD, Denmark; Dra. Juana Silva, Medical Doctor, Geriatrician, Chile; Stephanie Studenski, MD, MPH, United States; Artur Torosyan, MD, Armenia; Milagros Torres, MD, Venezuela; Nele Van Den Noortgate, MD, PhD, Belgium; Hana Vankova, MD, PhD, Czech Republic; Mark Anthony Vassallo MD(Melit.) DGM(Lond.) MA(Melit.) in Bioethics FRCP(Edin.) FRCP(Lond.), Malta; Michael Vassallo, FRCP, PhD, England; Gregor Veninšek, MD, Slovenia; Sol-Ji Yoon, MD, MPH, Korea.

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Over the past four decades, geriatrics models of care have emerged to address the unique needs of older adults. These models deliver evidence- based practices to this growing segment of our population. Some of these programs have been evaluated in randomized clinical trials. Other models have been evaluated as quality improvement projects. Identifying the needs of vulnerable older adults as they receive health care will allow geriatrics leaders the opportunity to respond to our patients’ needs with programs that improve care. Geriatrics models of care use interdisciplinary approaches to address the needs of patients with multiple comorbid conditions. This chapter with describe models based in the hospital setting and in the outpatient setting. Approaches and models related to transitions in care are discussed in Chapter 18, Transitions of Care.

Common goals of these geriatrics models of care include engaging patients and families in their plan of care, enabling patients to remain safely in the least restrictive site of care, and focusing on prevention strategies that optimize patients’ functional status and quality of life.

Geriatrics models of care commonly address a specific population of older patients. Models can exemplify how hospitals and health systems fulfill their mission within their community. Geriatrics leaders commonly need to build a case for geriatrics models of care to fit with the hospital/health system priorities, emphasizing efforts to continuously improve care. Working with key stakeholders in health care organizations, geriatrics leaders seek to identify the resources that are available to support a new model, define

where the model fits within other programs, and create a strategy to implement the model.

Table 14-1 provides several key components to geriatrics models of care. This chapter will help guide the reader to approach the framework of models of care and understand the key aspects of the design of various models.

Further, the reader will appreciate how to choose a model to deploy in their hospital or outpatient setting.

TABLE 14-1 ¦ KEY COMPONENTS TO SUCCESSFUL GERIATRIC BEST PRACTICE MODELS

Geriatrics models of care are standard approaches to the care of older adults. They are often deployed by geriatric medicine and gerontological nursing leaders in efforts to address the needs of populations of vulnerable older adults. Many were developed in response to common challenges of older patients (eg, functional decline or new onset of delirium during an acute illness). Most models are set within a single context of care (eg, the hospital or the clinic setting). Some models continue care beyond a single setting. Most models provide key screens and assessments for patients, as well as appropriate interventions in response to the unique needs of each individual. Models of care require interdisciplinary team members who work together as opposed to health professionals who work independently. Models are commonly targeted to address a vulnerable patient population during a specific context of care.

We will highlight a few important aspects to choosing a geriatrics model. First is to clearly define the local problem or challenge which you are trying to solve. This will require you to tell the story of the challenge in care and the implications for individuals. You likewise will need to describe the scope of the problem and implications for older adults and the costs. Second is to get support from key leaders and stakeholders because they are critical in efforts to improve care. Third in choosing a model is finding one that has

good evidence that it will work. We will describe the outcomes of various models later in this chapter. Next is knowing if the model is feasible in your setting. This means that you have the team and the resources to implement and sustain the program. Fourth is getting input from older adults and their family caregivers to guide choosing the model. Lastly is the ability to measure if the model will make a difference. Additional details on implementing, sustaining, and dissemination models of care will be highlighted later in this chapter.

Over the past decade, new concepts and strategies have emerged globally and nationally to incorporate the unique needs of our aging population. The World Health Organization (WHO), introduced the “age-friendly systems and communities,” a policy framework designed to address outdoor spaces and public building, transportation, housing, social participation, respect and social inclusion, civic participation and employment, communication and information, community support, and health services.

The John A. Hartford Foundation, in partnership with the Institute for Healthcare Improvement conceptualized the idea of “Age-Friendly Health Systems” (AFHS) (see Chapter 12 on Age-Friendly Care). The AFHS uses existing geriatrics evidence-based models of care to lessen iatrogenic adverse events to older adults, deliver the best care conceivable to older adults across all care settings (emergency departments, inpatient, post-acute, in home, and ambulatory), and effectively optimize value for all involved stakeholders. This concept was summarized as the 4Ms: (1) What Matters to the older person; (2) Medication; (3) Mentation; and (4) Mobility. Integrating the 4Ms into the design of geriatric models will help teams be more effective in addressing the needs of older patients. The AFHS approach uses regular meetings of key stakeholders toward implementing practice changes to improve care. National leaders help local teams to measure their care and improve outcomes. Geriatrics models of care can be the framework of these practice improvement activities.

Some geriatrics models of care have been evaluated in clinical trials while others have been described as rigorous quality improvement projects (Table 14-2).

TABLE 14-2 ¦ KEY FEATURES OF STRATEGIES TO IMPROVE CARE FOR OLDER PATIENTS

Quality improvement projects and geriatrics practice models each identify a clinical challenge. In both strategies, an institutional review board (IRB) waiver is required, a specific intervention is deployed, and outcomes are measured to see if it has worked. In each approach there is no new science defined. Usually the results are never made available in peer- reviewed journals. The work is often limited to one practice site. Both strategies are intended to improve the quality, safety, and value of health care. Both are unlikely to be disseminated, unless the model represents a unique improvement to health care. In summary, both geriatrics models and quality improvement programs use systematic efforts to improve care.

We would like to highlight some differences between geriatrics models and quality improvement. First, geriatrics models target specific interventions for older patients. They usually replicate prior work (eg, Acute Care for Elders [ACE] or Hospital Elder Life Program [HELP]), striving to get the same outcomes of the original model. Quality improvement projects, on the other hand, define the needs that fit their unique problems. Quality improvement projects allow the team to design their own approach to the problem commonly using “Plan-Do-Study-Act” cycles. These projects use experiential learning strategies. Second, quality improvement programs often have a shorter time frame whereas geriatrics models of care are commonly deployed over long periods of time. In summary, geriatrics models deploy a specific intervention to address a problem, while quality improvement projects allow more freedom to develop and implement an intervention.

Some geriatrics models integrate quality improvement strategies to improve their outcomes. An example of this is in the HELP program. The

leaders who implemented the HELP program in a local community noted that the outcomes for their program fell short of the original model. The leaders used simple quality improvement strategies to assess and manage the fidelity of the key ingredients of the model to eventually improve the outcomes.

Hence, geriatrics models of care may integrate quality improvement techniques into their project.

Geriatric Models of Care in the Context of Different Payment Mechanisms The financial incentive of the health system is a critical part of the environment in which models are developed and deployed (Table 14-3).

TABLE 14-3 ¦ EXAMPLES OF GERIATRIC MODELS OF CARE IN THE SETTING OF DIFFERENT PAYMENT SYSTEMS

Most geriatrics models have been developed over the past 20 years in the Medicare fee for service payment system. The fee for service payment system provides reimbursement based on the use of services, hence more care provided results in additional payment to providers and health systems. Models that work in these systems may rely on increasing downstream revenues to the health system from the care of patients. The fee for service payment system provides reimbursement to the hospital through diagnosis- related groups. In short, the Medicare fee for service payment system pays for services provided for the beneficiary.

The value-based purchase payment system provides reimbursement that spans unique episodes of care (see Chapter 19 on Value-Based Care). This payment system promotes optimal health outcomes with more efficient use of resources. An example of a value-based purchase systems are in accountable care organizations (ACOs), where optimal quality of care is rewarded along with the efficient use of resources. Examples of models that could be

beneficial to the patients and to the health system in the context of value- based purchasing payment models include Geriatric Resources for Assessment and Care of Elders (GRACE), ACE, and the HELP program. Models that could work better in these ACO systems would avoid hospitalization, readmission, and emergency department visits, and improve patients’ coordination of care.

Models deployed in a Medicare Advantage program provide care for the beneficiary and attempt to optimally use resources. The cost savings help keep the insurance premiums lower and may improve benefits offered to the beneficiaries. Models deployed in this payment system focus on avoiding hospitalizations. The economic benefit may result in lower total costs of care. Models that could be deployed in this payment system include GRACE and Hospital at Home. Some Medicare Advantage plans create an opportunity for geriatric leaders and health care leaders to implement geriatric models that would not have been possible in standard Medicare fee for service reimbursement care.

Trying to deploy a model that could save money in a fee for service payment system may not be endorsed by the health system, because such a model would not make enough money to be sustainable. Geriatrics leaders need to work with their health system leaders to review models that provide excellent clinical care and fit in a payment system that rewards such care. To prepare for value-based purchasing (while in the fee for service payment model), systems may need pilot programs which assess both quality outcomes and costs of care. Piloting these models can allow the hospital to study the economic benefit, while the clinicians assess the patient outcomes (Table 14-4).

TABLE 14-4 ¦ GERIATRIC MODELS OF CARE

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The ACE model is designed to prevent functional decline and to restore independent physical functioning in hospitalized, medically ill patients. The intervention merges principles of geriatric assessment with continuous quality improvement to prevent dysfunctional syndrome that results from hostile physical environments and processes of care and negative expectations of caregivers and patients (Figure 14-1).

Essential components of the ACE program include a prepared environment to enhance patient safety and independent functioning; patient- centered guidelines for patient assessment and management by nurses; medical care review to assure appropriate and safe medical care; and interdisciplinary team (IDT)-based care, which includes planning the patient’s transition to home or post-acute care setting. Daily IDT rounds briefly review each admission, with attention to the patient’s functional status, principal diagnoses and treatments, anticipated hospital length of stay, and post-acute care needs and expectations. The original model’s intervention was targeted at patients admitted to an ACE unit for any general medical illness.

The ACE program also pays attention to patients’ needs throughout their hospitalization and coordinates transitions of care based on function, cognition, and social situation. The IDT includes a geriatrician as medical director, geriatrics clinical nurse specialist (CNS), trained registered nurses, social worker, dietitian, and physical and occupational therapists. In the initial ACE unit model, attending physicians and internal medicine residents were welcomed to participate in IDT rounds or, if unable, to review their plan of care with the bedside nurses. In select situations, the team arranges for family/patient conferences to review diagnoses, therapies, advanced directives, and anticipated date of transition from hospital to home. Later iterations of the ACE unit include clinical pharmacists, chaplains, hospitalists, and case managers in the IDT. Geriatricians who participate in this model are paid by the sponsoring hospital administration through legal contracts.

The ACE model was initially studied on a medical-surgical nursing unit (the ACE unit). Three randomized clinical trials confirm the benefits of the ACE unit compared to usual care. Compared to patients receiving usual care those admitted to the ACE units were discharged with less disability and a shorter hospital length of stay. They were also less likely to transition to a skilled nursing facility. Total costs of hospitalization were slightly lower on the ACE unit. Trends toward less hospital-associated disability at discharge were shown in one study, with lower rates of disability or nursing home placement 1 year later. Caregivers, nurses, and physicians report higher satisfaction with patient care on the ACE unit compared to usual care. Other benefits of ACE demonstrated in the clinical trials and programs with elements similar to ACE included fewer patients falls and use of physical

restraints, better performance-based mobility, and reduced 30-day hospital readmissions. The most consistent outcomes of trials of ACE are significant reductions in length of hospital stay and costs. These findings provide compelling evidence that ACE units present health care systems an opportunity to realign the goals of improving the patient experience, providing high-quality care, reducing costs, and avoiding hospital-acquired conditions (consistent with the “triple aim”).

The strength of ACE units is their scalability in a health care system or large hospital. Clinicians have found it most feasible to define which older adults should not be admitted to the ACE unit (eg, those who need intensive care or those with unstable vital signs). Patient care is more efficient than usual care and additional costs for startup of the unit are modest compared to usual care once a unit is mature and necessary environmental alterations have been completed.

The major limitations of an ACE unit include the limited number of older patients who can be admitted to a small unit; the costs of initial model rollout, including training of nurse and team members; assembly and maintenance of the IDT; and the need to capture important metrics that demonstrate the “value proposition.”

Where an ACE unit is not feasible or unable to meet the needs of many older patients, the ACE program is modifiable as a “virtual ACE unit,” ACE without walls, or a mobile ACE program. The concept of an ACE unit is preserved, despite loss of unique environmental adaptations, as long as these programs attempt to maintain fidelity to the four core components: safe environment, patient-centered care, interdisciplinary team rounds to review medical care, and preparing for transitions.

The Mobile Acute Care of the Elderly (MACE) model consists of a mobile interdisciplinary team that includes a geriatrician, social workers, and clinical nurse specialists who consult on and provide care for older adult patients on medical-surgical units. The physical therapist, occupational therapist, and dietitian often are consulted to collaborate and coordinate care with the MACE team. The MACE team goals are to decrease the hazards of hospitalization, facilitate transitions of care, and provide patient and family education. In a clinical trial the MACE model was associated with lower rates of adverse events, shorter hospital stays, and improved satisfaction with transitions of care. Where a geriatrician is not available in a hospital, a quality improvement approach is the e-geriatrician consultation and an

automated electronic medical record spreadsheet of relevant items, called the ACE Tracker (Figure 14-2). Consultation can be offered off campus and the ACE Tracker provides a spreadsheet of quality measures, geriatric conditions, and risk factors for adverse outcomes, such as falls and pressure ulcers. The ACE Tracker is a tool that can guide the development of the care plan and has been helpful in disseminating the principles of geriatrics to remote and rural hospitals.

In the ACE consult service, the consultation model applies the same core principles as ACE without the unique environment. Consultation is performed by a geriatrician who often utilizes the expertise of the interdisciplinary team to comprehensively assess the patient’s overall medical and functional status and post-discharge care needs. Inpatient geriatric consultations focus on clarifying diagnoses, identifying goals of care, and addressing polypharmacy, delirium, dementia, cognitive impairment, frailty, elder abuse, neglect, malnutrition, dementia with behavioral and psychological symptoms, falls, functional decline, and

depression. Through a detailed review of the medical record and by obtaining key information from caregivers and family, geriatric consultations provide recommendations to the primary team. Geriatric consultation can be performed in multiple clinical settings in the hospital (Figure 14-3).

Geriatricians and nurse practitioners who see patients in this model bill Medicare Part B for their services. In some sites, the consultation is performed by nurse practitioners under the supervision of a geriatrician.

The HELP is a multicomponent intervention designed to prevent incidents of delirium in hospitalized older patients. The intervention consists of six standardized protocols for reducing specific risk factors for delirium: cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment, and dehydration. The intervention (Figure 14-4) is targeted at patients aged 70 and older with at least one risk factor for delirium.

The HELP intervention is conducted by an interdisciplinary HELP team. The team includes an advanced practice or geriatric-trained nurse, the Elder Life specialist, a geriatrician, and a program coordinator—the Elder Life Nurse specialist. The Elder Life Nurse specialist trains volunteers and oversees the interventions. The delirium prevention strategies are carried out by highly trained and supervised volunteers. The HELP team collaborates with a unit-based interdisciplinary team that includes nursing, medicine, physical therapy, occupational therapy, pharmacy, nutrition, and chaplaincy care. The HELP team assesses and enrolls patients who meet specific criteria and designate the delirium prevention strategies based on each patient’s needs. The HELP prevention strategies include a daily visitor program, therapeutic activities, an early mobilization program, nonpharmacologic sleep protocol, oral volume repletion, and a feeding assistance program.

The effectiveness of HELP was demonstrated in a prospective, individual-matching strategy, the Delirium Prevention Trial. The incidence of delirium was reduced by 40% among patients receiving the HELP intervention compared to the control group receiving usual care. The days spent delirious and the total episodes of delirium were significantly lower in the intervention group, although the severity of delirium and delirium recurrence rates were not lower. The individual attention given to each

patient by the volunteers and HELP team results in improved quality of care and reduced risks of hospital-associated conditions. The HELP program has been widely disseminated and integrated with other models, such as ACE units and Nurses Improving Care for Health System Elders (NICHE). The HELP model allows some flexibility in fidelity to the original model design. The national HELP program assists individuals to launch HELP by gaining support of hospital administration and staff. Hospitals that register for HELP assistance gain access to HELP manuals, training videos, handouts for families and caregivers, and information about national and local conferences.

HELP can be replicated and successfully implemented in medical units, surgical units, telemetry units, intensive care units, emergency departments, nursing home settings, and home care. HELP has been demonstrated to be both effective and cost-effective for patients at moderate risk of delirium.

HELP has also shown to improve quality of care of hospitalized older patients and patient and family satisfaction with care.

In multiple studies, HELP has been consistently associated with lower rates of delirium, functional decline, and cognitive decline, and decreased hospital length of stay and decreased rate of hospital falls. The effectiveness of HELP is directly related to adherence to the interventions and protocols. Limitations of the original HELP program include the need for trained volunteers. Recent adaptations of HELP give hospitals the option of using non-volunteers.

The most successful HELP programs have seen expansion of the program to many medical-surgical units and have documented substantial cost savings to their hospital. Geriatricians in HELP programs are paid through legal contracts with the sponsoring hospital for their time in completing specific job functions. HELP offers geriatricians superb opportunities: (1) to transform quality and safety of patient care at their hospital, (2) to be an expert consultant to the HELP team, and (3) to be a leader in interdisciplinary team care.

NICHE is a nursing care model designed to help hospitals and other health care organizations to improve quality of care for older adult patients and nurse competence in geriatric practice. NICHE principles and resources are consistent with professional nursing practice models. The program has

several approaches to infuse evidence-based geriatric best practices into hospital care. At the foundation of NICHE is the model of the Geriatric Resource Nurse (GRN). The GRN prepares staff nurses to serve as the clinical resource on geriatric issues to other nurses on a medical-surgical unit. Through education and modeling by a NICHE coordinator, educational protocols and tools enable nurses to implement best practices. NICHE focuses on improving nursing skills and knowledge when caring for older adults by providing training tools to hospitals and health care organizations. NICHE promotes the use of interdisciplinary teams and helps nursing staff to apply evidence-based concepts to care for older adults. NICHE provides tools for best practices to manage pain and prevent pressure ulcers, adverse medication events, delirium, falls, and the management of urinary incontinence. At a system level NICHE provides a structure for nurses to collaborate with other disciplines and coordinate geriatrics models of care. Hospitals can achieve NICHE designation to demonstrate the hospital’s commitment to improving quality and enhancing the patient experience.

Nearly 500 hospitals in the United Sates and several other countries are NICHE-designated. Many ACE units and HELP programs are based in hospitals with NICHE designation.

NICHE can be implemented in hospitals, long-term care facilities, and home health care practices. The NICHE program provides geriatricians the opportunity to collaborate with GRNs to promote geriatric quality of care and patient safety across the care continuum. Hospitals pay an annual fee to the NICHE program to receive all components of this model and educational resources.

There are two geriatric models called “STRIDE.” One is hospital-based and was studied in Veterans Affairs Medical Centers. The second is a falls prevention intervention that was deployed in outpatient primary care practices. The latter program is described in the section on Community- Based Models.

STRIDE (Assisted Early Mobility for Hospitalized Older Veterans) is a supervised walking program for hospitalized older adults focused on maintaining musculoskeletal strength and mobility during hospitalization.

STRIDE’s main features include: early assessment within 24 hours of admission, supervised ambulation, and education for the patient and their families that highlight the importance of daily ambulation. Patients admitted from a nursing home, planned surgery, bed rest order, chest pain, angina pectoris, new neurologic deficit, unable to follow a one-step command or cannot walk are excluded from the intervention. Patients are referred to this program by their treating physician.

The STRIDE intervention includes gait and balance assessment by a physical therapist, followed by supervised daily walks by a therapy assistant. The walk assistant follows specific protocols to ensure safety and monitoring of patient’s vital signs.

Initial studies have demonstrated that this supervised walking program for hospitalized older adults is feasible and safe, and program participants were less likely to be discharged to a skilled nursing facility than a demographically and clinically similar comparison group. A key aspect of this model is the emphasis on early mobility of hospitalized older adults. The premise that a nurse or physical therapist is not required makes this model compelling. Some sites have used physical therapy aides to implement this program.

Older adults with hip fractures generally have other comorbidities and geriatric syndromes that make them more vulnerable to experience complications when hospitalized.

Preexisting conditions and the risk of these patients to experience a complication postoperatively have generated the need to create geriatrics models of care that address the unique needs of older adults with hip fractures and multimorbidity.

AGS CoCare: Ortho is a Geriatrics-Orthopedics Co-Management model in which a geriatrician or specially trained clinicians work with orthopedic surgeons to coordinate and improve the perioperative care of older adults with hip fractures. This unique model of care focuses on training physicians, advanced practitioners such as nurse practitioners, and physician assistants to co-manage hospitalized older adults with the orthopedic team during the perioperative period. The training provided by this model covers a variety of topics relevant to older adults recovering from hip fractures. AGS CoCare: Ortho optimizes perioperative care in older adults. This model has

demonstrated improved outcomes, such as shorter time to surgery, reduced length of stay and 30-day re-hospitalization, lower complication rates, lower mortality, and institutional cost savings. Hospitals pay a fee to the AGS for access to this model. Geriatricians who work in this model bill Medicare when they consult on individual patients.

American College of Surgeons Geriatric Surgery Verification Program The American College of Surgeons (ACS) Geriatric Surgery Verification (GSV) Program is designed to take into account the surgical needs of older

adults. The program establishes standards to improve geriatric surgical care and better outcomes. The GSV Program provides a foundation for hospitals to take an interdisciplinary approach to augment perioperative care for older adults.

The standards set by the GSV Program are the result of the combination of rigorous evidence-based principles of geriatric care and empowering the interdisciplinary team to participate, coordinate, and monitor the quality of surgical care of this vulnerable population.

This program outlines standards in multiple areas with the ultimate goal to improve the quality of care for older surgical patients. These standards include, but are not limited to: improving communications with patients before surgical procedures to focus on outcomes that matter most to the patient, screening for geriatric vulnerabilities, better management of medications, providing geriatric-friendly rooms, revisiting goals of care for patients admitted to the intensive care unit, discharge planning coordination, and effective transitions of care.

The Perioperative Optimization of Senior Health (POSH) program was developed at Duke Health as a quality improvement initiative to coordinate the expertise of geriatrics, general surgery, and anesthesia teams. The POSH program provides integrated care coordination for older adults undergoing elective surgeries.

Patients are referred by the surgical team to an interdisciplinary team for preoperative assessment. The POSH preoperative team includes a geriatrician, geriatric resource nurse, social worker, program administrator, and nurse practitioner. This team focuses on targeted interventions such as management of multimorbidity, reduction of polypharmacy, improvement of

mobility and nutrition, and delirium prevention. POSH team physicians are also available as consultants to ensure the implementation of recommendations made preoperatively. The POSH team collaborates with the surgical team, assisting with the optimizing medications, pain control, treatment and management of chronic medical conditions, and postoperative complications.

The main objective of the POSH program is to improve postoperative outcomes for high-risk population. Studies have demonstrated that patients who participate in this interdisciplinary perioperative care intervention had shorter hospitals stays, lower readmission rates, and a greater likelihood of discharge home without a nursing home stay or need for home health care.

Patients in the POSH program also had overall fewer complications during their hospitalization.

The GRACE model of care of primary care was developed specifically to improve the quality of care for low-income seniors. The model integrates geriatric and primary care services across the continuum of care in expectation that patients will receive the recommended care. In the original model, eligible patients for the GRACE program are aged 65 or older, have an established primary care physician, are patients in the community-based health centers of a large health system, and have an income less than 200% of the federal poverty level. The intervention includes a support team of advanced practice nurse and social worker who help provide care for seniors in collaboration with the patient’s primary care provider and a geriatrics interdisciplinary team led by a geriatrician. The nurse practitioner and social worker support team performs an initial and annual in-home comprehensive geriatric assessment. The assessment includes medical and psychosocial history, medication review, functional assessment, and review of social supports and advanced directives. Their findings and recommendations are reviewed by the interdisciplinary team and discussed with the primary care physician. The interdisciplinary team also includes a pharmacist, physical therapist, mental health social worker, and community- based services liaison from the primary care practice. Based on the assessment and interdisciplinary team meeting, one or more of 12 GRACE

protocols are recommended. The protocols target common geriatric conditions: advance care planning, health maintenance, medication management, difficulty walking/falls, chronic pain, urinary incontinence, depression, hearing loss, visual impairment, malnutrition or weight loss, dementia, and caregiver burden. Relevant features of the intervention also include use of an integrated electronic medical record and a web-based care management tracking tool. GRACE collaborates with an affiliated pharmacy, mental and home health services, and community-based and inpatient geriatric care services.

A randomized controlled trial of the GRACE intervention was conducted with patients who met eligibility criteria and were assigned to either usual care by their primary care physician or to the support team and geriatrics interdisciplinary team in collaboration with the primary care physician.

High-risk patients enrolled in GRACE had fewer visits to emergency departments, fewer hospitalizations and readmissions, and reduced hospital costs compared to the control group. The 2-year program significantly reduced costs per enrolled high-risk patient by the second year. In addition, GRACE was rated highly by primary care physicians compared to usual care. GRACE-enrolled patients also reported higher quality of life compared to those in the control group for general health, vitality, social function, and mental health. The interdisciplinary team meeting occurred within 30 days of enrollment for 85% of patients, an average of 5.3 GRACE protocols were activated for each patient, and adherence to GRACE interdisciplinary team suggestions was very high.

The GRACE model of care appears to be cost-effective for low income patients who are at high risk for hospital readmission, and who receive medical care in a health care system that provides a wide array of supportive services. A barrier to greater implementation of the GRACE model is that only 10% of its costs are covered by fee for service Medicare. However, it appears to be ideal for managed-care practices and for ACOs who care for similar populations.

Several other hospitals, academic medical centers, and Department of Veterans Affairs Medical Centers have adopted the GRACE model of care. The GRACE model has been expanded to chronically ill homebound older patients as a home visitation program that includes physicians, nurse practitioners, and social workers. GRACE has been used successfully as a care transitions program for older adults who are discharged home from a

hospital or skilled nursing facility. GRACE has the potential to provide coordinated care management of enrolled patients across the care continuum with shared responsibility between patients, medical care providers, and the core team. It provides geriatricians an opportunity to serve in a consultative role to the interdisciplinary team and to be the primary care physician in various settings. The geriatrician’s expertise in chronic care management, interdisciplinary team care, knowledge of geriatric conditions, and training in system-based practice brings value to the health care system and insurance plans.

The Program of All-Inclusive Care for the Elderly (PACE) provides comprehensive primary care for participants who are aged 55 or older, certified by their state to be eligible for nursing home care, able to safely continue living in the community with services, and living in a PACE service area. The goal of PACE programs is to enable the participants to remain living in the community for as long as it is safe and feasible. Each PACE site receives capitated payments from Medicare and Medicaid, with funds covering health-related services required by participants. The services are primarily provided at a day health center, which in addition to medical care, provides nursing services, physical and occupational therapy, recreational therapies, meals, nutrition services, social work, and personal care. In addition, comprehensive services are provided at each PACE site ranging from primary care, specialty consultation, hospital and emergency services, and long-term nursing home care. PACE also covers home health and personal care costs, necessary prescription drugs, social services, respite care, and specific medical services, primarily at the day health center. An interdisciplinary team of professional and nonprofessional staff review goals of care with participants and family members; and meet frequently to review health status of participants to identify additional services or equipment that could enable the enrollees to remain living at home and to support caregivers’ needs. As a capitated program that is financially responsible for all Medicare and Medicaid-related services, the PACE site is incented to provide services that enable the enrollees to remain living in the community and to avoid unnecessary hospitalizations or medical interventions and therapies. PACE and the interdisciplinary team have flexibility for deciding how to pay for a participant’s medical and nonmedical expenses that enable

them to remain living at home. This flexibility enables PACE programs to provide services or durable medical equipment under the capitation model that are not typically covered by either Medicare or Medicaid. Nationally, most participants are older and have multiple morbidities and deficits in activities of daily living (ADLs), and about 50% have dementia.

As of 2021, 131 PACE programs were operational in 31 states. Although PACE programs serve primarily to dual-eligible participants, the Patient Protection and Affordable Care Act created an optional long-term care insurance plan that could be used to pay for community services such as PACE, creating the potential for an increasing enrollment in programs. More than 54,000 Medicare beneficiaries are enrolled in the PACE program.

Current barriers to enrollment in PACE programs include delays in enrollment of participants, limited number of sites in rural communities, lack of awareness of the program, and the requirement that enrollees transfer primary care to the PACE program.

Cross-sectional and cohort studies generally demonstrate that PACE programs enable enrollees to remain living in the community. Especially in mature programs, health care costs, hospitalization and readmission rates, and survival are better among enrollees in PACE compared to usual medical care settings that include case management and local community services.

With its focus on chronic disease management, interdisciplinary care, and system-based practice, PACE is an attractive model of care for geriatricians.

Stopping elderly accidents, death and injuries Stopping Elderly Accidents, Death and Injuries (STEADI) is a fall prevention initiative for health care providers designed by the Centers for Disease Control and Prevention (CDC). This is a coordinated care plan that focuses on older adults at risk for falls or those who already have a history of multiple falls. This model has three core elements: (1) screen patients at risk for falls, (2) assess modifiable risk factors, and (3) intervene to reduce risk factors. The intervention creates strategies to address gait, balance, and strengthening, optimize medications, and discontinue medications that increase fall risk. These strategies also include collaboration with other disciplines to evaluate sensory impairment (ophthalmologist), footwear issues (podiatrist), and home safety evaluations.

This coordinated approach has been demonstrated to reduce falls, improve health outcomes, and reduce health care expenditures.

Strategies to reduce injuries and develop confidence in elders program Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE) is a multifactorial intervention to prevent serious fall injuries. The STRIDE program is a patient-centered intervention delivered by nurses that partner with patient’s primary care physicians. (Note there is another program for older people named STRIDE [assiSTed eaRly mobIlity for hospitalizeD older vEterans].) This intervention assesses risk factors for fall injuries such as gait impairment, postural hypotension, vitamin D deficiency, home safety hazards, sensory impairment, and high-risk medications. This program deploys standardized protocols for management of specific risk factors. The care plans are individualized and reviewed by primary care physicians.

Follow-up care conducted by phone or in person and a review of care plans are other essential components of this intervention. A recent pragmatic, cluster-randomized trial that evaluated the effectiveness of this intervention did not show a significant lower rate of a first adjudicated serious fall injury. Nevertheless, clinicians can use these interventions to care for community- dwelling older adults, understanding the limitations of the evidence.

Home-Based Primary Care (HBPC) focuses on the frailest subset of older adults, those with severe and disabling chronic illnesses who receive primary care in their homes. The model is implemented in over 150 sites of the Veterans Affairs Medical Centers. Common conditions or illnesses of HBPC recipients include dementia, congestive heart failure, diabetes mellitus, chronic obstructive pulmonary disease (COPD), stroke, and severe arthritis. The program delivers care coordination at home with a team of geriatricians, nurse practitioners, social workers, licensed practical nurses, and office coordinators. Periodic follow-up by members of the team is complemented by on-call telephone coverage. Studies demonstrate improved quality of life of enrolled patients.

A Center for Medicare and Medicaid Innovation program, with similarities to HBPC, Independence at Home (IAH) is currently being implemented at multiple sites. IAH involves a mobility interdisciplinary team that rests on three pillars: targeting the highest-risk high-cost beneficiaries with limited

mobility, longitudinal HBPC with accountability for care received across all settings, and aligned quality metrics and payment incentives.

The IAH model has potential value for frail older patients who may be unable to make follow-up visits with a primary care physician in office due to disease complexity or frailty. To be eligible, beneficiaries must be enrolled in Fee for Service Medicare, have two or more chronic medical conditions, need assistance with two or more basic ADLs, and have had a nonelective hospitalization and received acute or subacute rehabilitation services within the preceding 12 months. The patient is seen for a first home visit within 24 to 72 hours of hospital discharge. A comprehensive evaluation of their physical, medical, and functional needs, and of their caregiver’s needs, is included in this first visit. Follow-up visits involve close contact between the nurse practitioner and home health agency.

Analysis of administrative data demonstrates that the model is associated with a decrease in the use of hospital resources and cost reduction. In a case- controlled study of Medicare patients enrolled in a home care intervention, total costs were 17% lower over a mean of 2 years of follow-up. With the aging of the very old population and financial incentives favoring home care versus hospital or institutional treatment of frail patients, IAH offers opportunities for geriatricians to become both directors of programs and providers of home care.

CAPABLE is a program developed for low-income seniors to safely age in place and improve physical function. This interprofessional program includes an occupational therapist, a registered nurse, and a handyman.

The CAPABLE interdisciplinary team focuses on identifying daily activity goals in a community dwelling for older adults (eg, taking a shower and walking to the bathroom), evaluating barriers to achieving those goals, and monitoring outcomes collaboratively. The occupational therapist assesses patient’s ADLs and instrumental ADLs (IADLs), and pays attention to activities that are challenging at home, such as functional mobility, meal preparation, bathing, and dressing. The registered nurse targets underlying issues that can potentially affect ADLs or IADLs, such as pain and mood. A registered nurse will also address fall prevention, medication review, incontinence management, sexual health, and smoking cessation. She

communicates concerns to the primary care physician. The main goals of CAPABLE are to increase mobility, functionality, and ability for older adults to age in place, using their strengths to maximize safety and independence.

CAPABLE has been demonstrated to improve ADLs and IADLs and quality of life, lower hospitalization rates, and reduce fall rates.

The UCLA Alzheimer’s and Dementia Care (ADC) Program is designed to assist patients with Alzheimer disease and related dementias (ADRDs). This program is a health system-based co-management model that uses a nurse practitioner supervised by a physician dementia specialist who works with primary care and specialty physicians to ensure the care of these patients is comprehensive and coordinated. The goals of this program are to maximize patient function, minimize caregiver burnout, and reduce unnecessary costs through improved care.

Patients are referred to the UCLA ADC Program by primary care physicians or specialty physicians. Key components of this program include structured needs assessment of patients and their caregivers; creation and implementation of individualized dementia care plans; ongoing dementia care management (caregiver education and training, coordination of care with neurology, geriatric psychiatry, psychology, or geriatrics, caregiver support groups, referral to community-based organizations for services); and access to a geriatrician for assistance and advice. The UCLA ADC Program monitors and revises care plans, as needed, including active monitoring via phone call or in person visit (a minimum of a telephone interaction every 4 months). The UCLA ADC Program has demonstrated outcomes of improved quality care, lower-cost expenditures, and better clinical outcomes.

Gerofit is an exercise and health-promotion program for older veterans. Gerofit program targets deconditioned older adults with chronic medical problems who use assistive devices and are at risk for functional decline. Patients are referred to this program by their primary care provider.

Individuals eligible for this program must be aged 65 and older and able to function independently in a group setting. Patients with inability to perform basic activities of daily living, inability to transfer, oxygen dependence,

unstable cardiac disease, and moderate to severe cognitive impairment are excluded from the program.

Participants enrolled in the program have demonstrated improved health, mental health, physical function, and well-being. A recent dissemination study showed that Gerofit has better long-term outcomes, such as a delayed need for institutional care, sustained improved functional abilities, improved well-being, and lower mortality, than usual care.

There are several important lessons to share as the field moves from studying a geriatrics model of care to the actual implementation of the model. Some leaders describe multiple efforts to propose different models over a period of several years without getting hospital “buy in” for their ideas. Other models are championed by the health system as a priority in fulfilling a key aspect of their mission. The implementation of a geriatrics practice model can be an exciting and fulfilling aspect of a geriatrician’s career. An understanding of implementation science and the ability to work with teams are two important principles in leading geriatric practice models.

First, geriatrics models must be deployed to address the local problems in the health care delivery system. An example would be if the nursing staff is struggling with a high rate of delirium among their older patients.

Describing the problem with a patient story can help communicate the need for the program. In this context, the geriatrics leader could propose the development of a structured intervention (eg, the HELP program) with the engagement of the nursing administration. Identifying and addressing the contextual issues will increase the chance of successfully launching the model of care. The context further includes the culture of your organization and the economics of payment for health care at your site.

with the administration provides a good working relationship and increases the validity of the information.

Third, your planning team needs to develop a business plan and a communication plan with the hospital administration, to get approval to proceed with model implementation. This plan outlines the costs and the potential savings of the geriatrics model. The philanthropy (or development) office can assist in launching your model by reaching out to prospective donors and securing grant funds to cover startup costs. Often the geriatrics leaders present a description of the new model and the business plan to an administrative executive team to get input and buy-in. The geriatrics leaders should make sure that the administration has agreed to the model before moving forward with full implementation. Once the planning team has gotten the agreement from the administration, one needs to define the roles of each team member and determine what the exact intervention entails. Finally, your team will need a communication plan to make sure that all stakeholders understand the model and their roles. In summary, there are key steps to the implementation of a geriatric model that can assure that the program has been successfully launched.

While it is exciting to launch a geriatrics model, it is difficult to sustain that model over a long period of time. Six key points deserve some attention in this regard. First, your geriatrics model “planning team” can be converted to an “advisory committee” charged with reviewing outcomes and guiding the project over time. This group can identify challenges and find resources to address the identified needs. The advisory committee is not charged with personnel decisions or day-to-day management of the model. A patient should serve on this committee to help keep the team patient-centered. An annual report should be provided from the advisory committee to the hospital or funding organization to describe key outcomes and number of lives touched by the program.

Second, geriatric models may not initially improve outcomes. The hospital leadership should be able to define the key outcome measures benchmarked over time and explain if the program worked. If it appears that the outcomes are not being achieved according to the benchmarks, the leadership team will need to assess the fidelity of the model and the reliability of the measures. Leaders may be able to use baseline outcome

measures prior to the implementation of the interventions in making these determinations. The post-intervention measures can help explain if the model is improving outcomes. Validated and endorsed quality measures should be used whenever appropriate to benchmark against national performance. The leadership and the advisory team can guide the program, even if initial improvement is not achieved. In advising how to move forward, we have learned to pay careful attention to (1) the communication of the model to key stakeholders, (2) the training of the professionals who are key personnel in the model, and (3) the assessment/maintenance of the fidelity of the models.

Third, yearly personnel goals should be used to align individual employee goals with the goals for your geriatrics model. As an example, the Elder Life Specialist of the HELP model could have as his/her annual goal with the consistent use of all six of the delirium prevention protocols. This effort of using yearly personnel goals helps keep the leaders and the employees focused on achieving full implementation of the geriatrics model. This effort further rewards the employees for their contributions.

The fourth point in sustaining a geriatrics model is to make sure that model leaders continue to communicate with key stakeholders. Physicians and nurses who are providing clinical care will need to understand the importance of excellent care of older individuals in their community.

Likewise, other health care professionals will need to understand the program and their role in the geriatrics model. Further, community leaders from the department on aging and the local Alzheimer’s Association will need to understand the geriatrics model and how they can partner with your programs.

Fifth, careful attention to the funding of your geriatrics model is critical. The costs and savings of the geriatrics model will be important to sustaining the hospital support for the model. Billing and reimbursement from Medicare and other insurers should be carefully tracked, as should compliance with billing requirements. By following these outcomes, your team can responsibly manage resources. You can determine the direct variable costs per patient in your model and compare these costs with those of a matched cohort of patients receiving standard care. This effort can help make the case for further expansion of your program. Partnering with administrative colleagues who can help prepare these reports and can assist with program budgets will result in accurate and trusted reports.

Sixth and finally, compare your outcomes with other sites to try to find “best practices.” This assessment may help your team to define what exactly is being done at each site and adjust processes to further improve outcomes. Again, using standardized outcome measures is essential in order to compare outcomes across sites.

A few key points are important for “scaling up” geriatrics practice models. We have learned that the geriatrics leaders must articulate a clear message about how the model will be implemented broadly into practice. Your team must get agreement that the goal of spreading the geriatrics model broadly in the hospital or health system is consistent with the organization’s mission.

The geriatrics team must mobilize across a wide area to communicate the new model to “early adopters,” so that the effort is implemented at new sites. The message will need to address: Exactly what will be done? Who is eligible for the model and who is not? What outcomes will be measured to know we have made a difference? The practice model must be communicated to the opinion leaders in the field, so that their input is considered as the model is rolled out. The University of New Mexico Project ECHO has developed effective methods to disseminate best practice. The four key components of Project ECHO include: (1) using technology to leverage scarce resources, (2) sharing best practices to reduce disparity, (3) deploying case-based learning to master complexity, and (4) monitoring outcomes using a web-based database. In summary, one of the most challenging aspects of implementing geriatrics models is the broad dissemination of that model into standard practice. The role of the geriatrician in this work is to lead a broad coalition of health providers toward a common goal of better care for older patients.

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As populations worldwide age, older adults seek emergency care with increasing frequency. Based on current population projections in the United States, the number of individuals over age 65 will more than double while those over age 85 will triple by 2060. Emergency departments (EDs) already functioning as society’s health care safety net will evaluate and disposition more complex older adults than in prior decades, often serving as the front porch of the hospital with expectations to cost-effectively manage admission rates and maintain patient flow. Unfortunately, the rapid evaluation model of emergency medicine that generally serves younger populations efficiently (Figure 15-1A), is an ineffective model for geriatric emergency care (Figure 15-1B). Recognizing this demographic shift, emergency medicine and geriatric professional societies responded over the past decade with core competencies for emergency medicine residency trainees, clinical practice guidelines, and pragmatic quality indicators.

FIGURE 15-1. (A) Traditional emergency medicine management pathway. (B) Geriatric emergency care model.

The aforementioned Geriatric Emergency Department Guidelines, endorsed by the American College of Emergency Physicians (ACEP), American Geriatrics Society, and Society for Academic Emergency Medicine in 2013, provided the requisite framework for ACEP’s Geriatric

Emergency Department Accreditation (GEDA) program that launched in 2018 and has accredited nearly 300 EDs worldwide (https://www.acep.org/geda/). In order to attain accreditation, hospitals (not just EDs) must demonstrate a commitment to focused geriatric care processes via quality improvement efforts and their associated metrics that often require transdisciplinary coordination between geriatrics, emergency medicine, physiotherapy, nutrition services, hospitalists, primary care teams, and outpatient services. In addition, the Geriatric Emergency Department Collaborative (GEDC) arose to provide a transdisciplinary learning network of geriatric ED teams to share innovative ideas, solutions, and common lessons around the cost-effective improvement of older adult emergency care (https://gedcollaborative.com/). Internationally, the Silver Book II synthesizes best practices for the acute care of frail older adults from a multidisciplinary perspective. This chapter will review components of the Geriatric Emergency Department Guidelines and Silver Book II, as well as facilitators and barriers to widespread implementation of these guidelines.

The concept of an ED specializing in older adult processes and outcomes of care was first broached in 2007. Adapting the physical environment to a more geriatric-friendly space was noted at that time (Table 15-1). Improving the ED infrastructure alone, however, is inadequate to optimize older adult health care delivery and outcomes. Geriatric-focused continuing medical education, appropriate staffing, and protocols aligned with local resource availability are more important than the physical space in which emergency care occurs. Education and protocols should focus on the detection, prevention, or management of geriatric syndromes that frequently present to the ED (Table 15-2). Continuing medical education that uses the case of an octogenarian acute myocardial infarction or cerebrovascular accident to highlight the latest pharmaceutical or biomedical device is not considered geriatric in this context. Essential components of older adult-relevant medical education in the Geriatric Emergency Department Guidelines should incorporate the identification and management of aging-related syndromes such as delirium, falls, frailty, or polypharmacy in the setting of emergency

care. Similarly, for ACEP’s GEDA program, a general hospital-wide policy to reduce unnecessary urinary catheters regardless of age would not necessarily be considered a geriatric-emergency medicine focused protocol unless adapted to evaluate measures in Table 15-2. GEDA emphasizes an interdisciplinary staffing approach corresponding to the specific quality improvement efforts. If those efforts include reducing polypharmacy to promote medication safety then including a pharmacist in the ED (or readily available to the ED round-the-clock) with geriatric medication safety expertise or interest is encouraged. Because the ED will continue to be a societal safety net for all populations, geriatric-centered care, design, staffing, and continuing medical education may differ from that used in clinic settings or hospital wards.

TABLE 15-1 ¦ GERIATRIC EMERGENCY DEPARTMENT INFRASTRUCTURE

A range of 6% to 38% of ED adults over age 65 present with (prevalent delirium) or develop (incident delirium) delirium. Hypoactive delirium is more common than hyperactive delirium, yet has been identified by ED nurses and physicians far less frequently. Delirium is a transient symptom precipitated by an acute stressor or physiological insult, but is associated with an increased hospital length of stay, cognitive and functional decline, and post-hospital depression. Common precipitating factors are summarized in Table 15-3. ED nurse or physician judgment alone is inadequate to identify delirium accurately, so over 20 delirium screening instruments have been evaluated in this setting. Although the Confusion Assessment Method has been studied more frequently, the brief Confusion Assessment Method (bCAM), Richmond Agitation Sedation Scale, and the 4AT more favorably balance brevity, accuracy, and emergency provider acceptability (Figure 15- 2). Since delirium is a symptom of an underlying physiological stressor, geriatric emergency care should try to identify the precipitant(s) of delirium (Table 15-3). Accurately identifying and treating the cause of delirium will require collaboration with inpatient services because patients with delirium who are discharged home without treating the delirium will return to the ED.

TABLE 15-3 ¦ RISK FACTORS FOR DELIRIUM

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At least three pragmatic barriers exist to improving the detection, prevention, and management of delirium in the ED. First, simply publishing research or synthesizing recommendations into guidelines will not modify clinician behavior. Implementation Science or local quality improvement efforts are required, which is the rationale for GEDA and GEDC to catalyze uptake of these principles. Second, even if ED teams incorporate one or more of the delirium screening instruments into routine practice, hospital providers often use different delirium detection tools and are unfamiliar with those used in emergency settings. Unfamiliarity breeds skepticism, which impedes efficient communication and harmonization of efforts to align diagnostic testing priorities, disposition decisions, and immediate management steps. Incorporating instruments used in non-emergency medicine settings may reduce reliability and/or accuracy. While awaiting research to harmonize dissimilar screening tools, clinicians should proactively communicate about delirium concerns and management with other health care teams and settings. Third and perhaps the most challenging scant proof-of-concept currently exists to guide actionable next steps for the prevention or treatment of delirium in the ED. While diurnal lighting and frequent reorientation described in Table 15-2 seem appropriate, these strategies remain untested in ED or geriatric ED settings. Whether pharmacologic or nonpharmacologic strategies can reduce the incidence, duration, or severity of delirium remains to be proven.

TABLE 15-2 ¦ GERIATRIC EMERGENCY DEPARTMENT SYNDROME

Delirium and dementia frequently overlap in older adults in ED settings. When delirium is excluded as the cause of cognitive dysfunction in older ED patients, approximately 31% of all patients over age 65 still have a concern for cognitive dysfunction, specifically dementia. Whether recognized or not, ED patients with dementia (or possible dementia as many lack additional neuropsychiatric evaluation in the weeks to months after an episode of emergency care), this non-delirium cognitive dysfunction is associated with prolonged length of stay, fall risk, admission rates, return visits and readmissions, and patient/care partner dissatisfaction with the care provided. When features concerning for dementia are missed in ED settings, inpatient services also frequently miss subtle findings and opportunities to improve care transitions are neglected.

While eight dementia screening instruments have been evaluated in ED settings, those that balance brevity and accuracy are favored by clinicians, including the Abbreviated Mental Test (AMT-4), Ottawa 3DY (O3DY), and caregiver-administered Alzheimer’s Disease-8 (cAD8) summarized in

Figure 15-3. The cAD8 has the advantage of not relying upon an available, communicative, or cooperative patient in the ED where patients are often undergoing various tests and consultant evaluations. In addition, whereas AMT-4, O3DY, and most other dementia screening instruments often yield false-negative findings for more highly educated individuals, the cAD8 does not because it employs a knowledgeable care partner to report a cognitive change from baseline rather than a memory or performance test of the patient.

The recognition of possible dementia in an older ED patient affects clinical decision-making. While dementia may not be viewed as a medical emergency, the psychosocial model depicted in Figure 15-1B necessitates that effective geriatric emergency care contemplate cognitive capacity. If

otherwise medically stabilized, is this patient safe to be discharged? Does the patient understand the discharge instructions, medications prescribed or deprescribed, and follow-up plan? Will the patient remember those factors after discharge? Although reflexive hospital admission is probably not the appropriate management option, transitions of care must be adapted for patients with suspected cognitive dysfunction.

Pragmatic and unanswered barriers exist to widespread dementia screening for older adults in the ED. First, these screening tools are not diagnostic for dementia. Most have positive likelihood ratios ranging from 1 to 4 and negative likelihood ratios from 0.17 to 0.39 when defining “dementia” using imperfect criterion standards such as the Mini Mental Status Exam. Clinicians and diagnosticians need to balance the theoretical value of non-delirium cognitive dysfunction screening against the possible harm of eliciting preventable anxiety for patients and families around the diagnosis of dementia. Second, inpatient and outpatient providers may be unfamiliar with ED dementia screening instruments, which can impede efficient between-clinician communication. Third and similar to delirium screening, the “so what?” implications of dementia screening remain poorly defined. Since dementia is incurable, screening has no direct therapeutic response for ED teams and dementia screening alone does not identify a cohort more likely to benefit from admission. Additionally, the impact of dementia screening on patient and family satisfaction ratings is uncertain and the cost of training/maintaining ED staff to evaluate for dementia and provide follow-up resources to higher risk individuals remains undefined.

Abuse of the older adult can take many forms, including physical or psychological harms, financial exploitation, or neglect. Although up to 10% of older adults in the United States experience some form of abuse each year, as few as 1 in 14 cases are reported. Screening for elder abuse in ED settings is frequently fraught with challenges, including a paucity of research to guide screening protocols and effective interventions as well as the ethical quandary of patient denial motivated by fear of retribution by the perpetrator. Nonetheless, the clinical and forensic science of detecting and preventing elder abuse continues to evolve. The Senior Aid Tool (Figure 15-4) is a sensitive and reasonably specific screening instrument for elder abuse, but

awaits external validation, feasibility assessment, and impact analysis demonstrating benefits beyond improved detection rates.

FIGURE 15-4. Emergency department (ED) Senior Aid Tool to screen for elder abuse.

Preventing elder abuse requires a team-based approach that begins in the pre-hospital environment and continues through the ED into the post-ED setting with coordinated communication between social work, nursing, physicians, and law enforcement. Some hospitals have established “Vulnerable Elder Protection Teams” to standardize and coordinate the detection, comprehensive evaluation, and treatment for potential victims of elder abuse. ED elder abuse experts recommend simplifying data collection forms that include photographic evidence of visible injuries as well as documented and coordinated communication with radiologists when common injury patterns appear.

Individuals over age 65 comprise one-fourth of trauma admissions with ground-level falls becoming an increasing proportion of those cases as populations age. Among community-dwelling older adults over age 65, one-

80. An ED evaluation for a fall is often the only medical contact these patients have and an opportunity to prevent future fall injuries. Yet 36% to 50% of these patients experience a recurrent fall, ED revisit, or death within 1 year of an initial fall.

ED nurses and physicians acknowledge a role in proactively preventing future fall injuries for frail older adults, but cite pragmatic barriers to routine fall prevention secondary to inadequate training around risk stratification, insufficient emergency medicine-specific fall assessment tools, and uncertain access to downstream fall prevention resources. Part of the problem is that falls are often complex and multifactorial with predisposing fall risks (Figure 15-5A), diminished physiological factors to avoid fall injuries (Figure 15-5B), and an increased risk of injuries from ground-level falls (Figure 15-5C). Furthermore, there is no widely accepted post-ED fall risk assessment instrument. Another barrier to routine fall prevention initiatives is the perception of therapeutic nihilism since complex and individualized interventions often fail to reduce fall-related injuries. For example, the Strategies to Reduce Injuries and Develop Confidence in Elders pragmatic randomized controlled trial utilized risk assessments to formulate individualized fall prevention interventions, yet failed to effectively prevent the first injurious fall. Similarly, an ED-based randomized controlled trial to deprescribe medications associated with increased fall risk did not reduce falls at 1 year. However, another academic ED protocol that incorporated physical therapy and pharmacy to formulate a brief and individualized intervention during a visit for a fall reduced both overall and fall-related revisits at 6 months. Feasible approaches for ED initiated secondary falls prevention undoubtedly require a local champion, transdisciplinary coordination, and accessible resources to promote patient cooperation (Figure 15-6).

FIGURE 15-5. Understanding geriatric fall risks and factors related to injurious falls. Figure 15-5A depicts the older adult prior to a fall and illustrates the intrinsic (physiological attributes of the individual) and extrinsic (environmental surroundings) that can be related to a fall. Some of these factors are evidence-based from epidemiological studies (denoted with “*”), while others are recognized by the clinician authors of this review. These risk factors include (A)

disequilibrium*, (B) visual deficits, (C) dysrhythmia, orthostatic hypotension, (D) degenerative joint disease and rheumatic disease*, (E) loose fitting clothing, (F) poorly fitting footwear or foot sores, (G) pets, (H) rugs or loose mats, (I) dementia, Parkinson disease*, (J) malnutrition, (K) deconditioning, frailty, muscle wasting, (l) preexisting stroke or other motor deficit*, (m) slippery surface, (N) stairs, (O) walker or crutches, (P) medications (sedatives)*, alcohol, (R) inadequate lighting, (S) transfers from sitting to standing, and (T) urinary incontinence*. Figure 15-5B depicts intrinsic and extrinsic factors that render older adults more likely to suffer a fall than a near-fall. Whereas younger populations sometimes suffer near-falls, they rarely fall to the ground and when they do the kinetic energy of the fall is usually disrupted by a variety of adaptive protection responses that are slowed, diminished, or absent in frail elderly persons.

These factors include (A) impaired reflexes to ease fall, (B) lack of handrails, (C) cluttered furniture, (D) diminished awareness of falling, (E) impaired proprioception, and (F) diminished core body strength. Figure 15-5C illustrates the physiological, pharmacological, anatomical, and environmental factors that increase the probability of the primary fall injury severity for the mechanism and energy of a fall becoming more pronounced and for secondary injuries to ensue. These factors include (A) osteoporosis = fractures with minor trauma, (B) spinal cord stenosis and cervical spine degenerative disc disease = spinal cord contusion (anterior cord syndrome),

= increased risk of intracranial (and other) bleeding, (E) muscle wasting = inability to rise and “long lies,” (F) diminished body fat/padding = more force to brittle bones, and (G) frail skin = tears and lacerations. (Reproduced with permission from Michael L. Malone, Christopher Carpenter. Graphic artist: Brian Miller. Aurora Health Care. Copyright 2017.)

Figure 15-6 illustrates the real-world settings of falls prevention research moving forward: the outpatient clinic, the ED, the homes of older patients, the practice sites of nurse case managers and physical therapists, and the community. Identifying effective falls prevention strategies in post- STRIDE research necessitates a multipronged approach incorporating Implementation Science principles and an evolving understanding of impactful shared decision-making. Transdisciplinary alignment and harmonization of fall-related definitions, screening instruments, and outcome measures while catalyzing impactful change can promote healthy skepticism while avoiding therapeutic nihilism and advance patient-centric falls prevention. Rapidly learning health systems can integrate incremental improvements from multiple settings to improve their research and clinical practice.

As the proportion of older adults presenting to EDs increases in coming decades, health care systems will seek screening processes to identify subsets more or less likely to experience preventable short-term adverse outcomes, such as return visits, functional decline, institutionalization, or death. Many instruments exist to quantify such “vulnerability” (Table 15-4), but currently none accurately identifies either a high-risk or low-risk subset. Reasons underlying inadequate accuracy of these instruments include between-study variability in processes, definitions, interventions, outcomes, and objectives. One approach to align finite resources with populations most likely to benefit is depicted in Figure 15-7. Researchers continue efforts to derive more accurate instruments, while clinicians focus low intensity and

widely available interventions on commonly harmful scenarios such as falls and delirium as previously discussed.

TABLE 15-4 ¦ CURRENT STATE OF GERIATRIC ED “VULNERABILITY” INSTRUMENTS

FIGURE 15-7. Approaches to advancing geriatric emergency department “vulnerability” screening research. Option 1, proposed by Heeren et al. would cease efforts to derive more accurate instruments than currently exist in order to focus on hybrid-effectiveness research. Alternatively, Option 2a would adapt prior methods to derive “vulnerability” instruments that incorporates pre-emergency department data, dynamic re-evaluations throughout emergency department episode of care, social and system factors, and current disease severity – perhaps using disruptive innovation such as machine learning. Option 2b could occur simultaneously with 2a, while responding to risk identified by current imperfect instruments with widely available and generally acceptable interventions. More labor-intensive interventions like Comprehensive Geriatric Assessment would be reserved for high-resource settings or clinical research like Plan- Do-Study-Act (PDSA) cycles.

Frailty is an increased vulnerability to incomplete homeostasis after a physiological stressor. While early constructs of frailty failed to identify ED older adults at increased risk of preventable short-term adverse outcomes to the same extent as the instruments described in Table 15-4, the Clinical Frailty Scale appears to be a feasible, accurate, and reliable instrument to predict 30-day mortality. Whether the Clinical Frailty Scale can stratify older adults into higher or lower risk of return visits or functional decline, or if such identification can be linked to interventions that alter that trajectory, remains to be determined.

The ACEP Geriatric Emergency Department Guidelines and emergency medicine resident core curriculum both emphasize the importance of identifying and deprescribing high-risk medications primarily guided by

Beers Criteria. However, Beers Criteria generally apply to the longer duration prescriptions provided in long-term care or outpatient clinic settings. The short time frame prescriptions commonly provided in the ED may represent a unique risk–benefit profile that remains relatively untested. Therefore, Beers Criteria are not unquestionably accepted as an indication of high-risk medications by ED teams. Nonetheless, Beers Criteria are frequently used in research and guidelines as one component of inappropriate medication prescribing for older adults. The Enhancing Quality of Provider Practices for Older Adults in the Emergency Department (EQUiPPED) protocol combines education with personal provider feedback and electronic clinical decision support to improve medication safety. Across four Veteran’s Affairs hospitals, EQUiPPED demonstrated a significant and sustained reduction of potentially inappropriate medication prescribing at 1 year.

EQUiPPED implementation kits for accelerated uptake of this medication safety initiative have also been developed in non-Veterans Affairs EDs.

Apart from these protocols, ED clinicians should be continuously aware of the potential of drugs to cause or exacerbate symptoms and interact with each other or with underlying diseases. In addition, many older adults are overtreated with hypoglycemic and antihypertensive medicine, which can result in ED visits. In these circumstances ED clinicians should initiate a deprescribing effort and communicate their findings and recommendations to the patient’s physicians either through the patient or directly.

As clinical researchers unravel the science of efficacious and cost-effective geriatric emergency care, others continue to expand the realm of possibilities with disruptive innovation. The original vision to enhance the process, experience, and outcomes of older adult emergency medicine depicted a dedicated location in the department distinct from sites where care for other populations occurred. Improving older adult emergency care need not rely upon a localized geriatric ED because many hospitals will lack the resources for this investment. Instead, alternative approaches include a geriatric observation unit, a focused practitioner model, or simply a site opinion leader to facilitate continuing medical education and local quality improvement initiatives. Adults over age 65 already represent over 30% of

observation unit admissions, which is disproportionate to their overall ED volume. The observation unit can serve as another option to hospital admission by providing time to evaluate therapeutic response, obtain additional testing or consultations, and facilitate care transitions. The focused practitioner model can include a physician-led, trained geriatric emergency medicine (GEM) nurse or transitional care nurse, as well as lesser-trained personnel such as a “geriatric technician”–based volunteer model. In two observational studies across three academic hospitals, transitional care nurses reduced admission and readmission rates, but increased 72-hour returns. The GEM nurse model requires a significant investment in extra training and appears to increase geriatric syndrome screening rates. Establishing a qualified volunteer-based program in the ED requires an institutional commitment, continual onboarding and quality control processes, and a health care provider leader, but has been successfully implemented at two large academic centers with reasonable acceptance by nurses and physicians.

The twenty-first century technology revolution will inevitably affect geriatric emergency medicine as well. During the COVID-19 global pandemic when patients shunned EDs for fear of exposure to the life- threatening virus, telemedicine emerged as a viable alternative for acute care. Potential (and untested) applications of telemedicine for geriatric emergency care include evaluation of stable long-term care facility, rehabilitation unit, homebound, or rural patients who have a change in condition prior to transfer to an ED. This can be done in collaboration with the patient’s primary care providers and/or paramedics. In addition, more resourced geriatric EDs with personnel available to screen for geriatric syndromes described in Table 15-2 could remotely assess patients via telemedicine. Other emerging technologies that can catalyze improved geriatric emergency care without adding work for ED staff include pad- based screening for delirium and machine learning approaches to detect individuals at risk for dementia, delirium, falls, or other geriatric syndromes.

Sustainable and measurable geriatric emergency medicine advancement requires a village that extends beyond one specialty, discipline, or hospital locale. It must incorporate collaborative, transdisciplinary personnel and

adapt around the infrastructure of the local ED to be successful. Ultimately, widely implementable improvements in the process, experience, or outcomes of geriatric emergency care must be cost-neutral and patient-centered. As clinical research expands around geriatric emergency medicine assessment accuracy and intervention effectiveness, guidelines and accreditation will continue to catalyze health care systems to engage in process redesign.

Emergency care must become more adept at addressing the needs of an aging population and not allow perfection to impede necessary but incremental improvements.

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The focus of this chapter is the clinical care and support of nursing home (NH) residents. In this chapter we use the term “nursing home.” However many terms are used in the US to describe the same types of facility, including “nursing facility,” “skilled nursing facility or SNF,” long-term care facility or LTCF, and “rehab facility.” In the US there are approximately 15,500 NHs with approximately 1.5 million beds. The vast majority are certified as SNFs (approximately 90%) and provide both short and long-term care, and the rest provide long-term care only (see Figure 16–1).

Many older people who previously would have been in NHs now reside in assisted living residences or in their own homes. Support for older people with multiple chronic conditions in the NH setting is challenging for a number of reasons. Although many NHs provide excellent care, the poor quality of care provided in some NHs has been recognized for decades.

As older NH residents suffer from multiple underlying conditions, high quality clinical care is especially important. [Note: in this chapter we use the term “residents.” However, many short-stay individuals are termed “patients” by many providers of NH care.] Despite the logistical and economic barriers that can foster inadequate care in NHs, many basic principles and strategies can improve the quality of care for NH residents.

Fundamental to achieving these improvements is a clear perspective on the goals of NH care, which differ in some respects from the goals of medical care in other settings and populations.

The modern NH supports residents in multiple ways. Table 16-1 lists the key goals of NH care and support. While the prevention, identification, and treatment of chronic, subacute, and acute conditions are important, these goals are undergirded by a focus on functional independence, autonomy, quality of life, comfort, and dignity of residents. Physicians, nurse practitioners, physician’s assistants, and other clinicians must consider these

comprehensive, person-centered goals and at the same time address the more traditional goals of medical care.

TABLE 16-1 ¦ GOALS OF NURSING HOME CARE

The heterogeneity of the NH population results in diverse goals set by or with NH residents. There are five basic categories of NH residents (Figure 16-1). Subgrouping NH residents in this manner will help clinicians and the interdisciplinary team focus the care-planning process on the most critical and realistic goals that matter most to individual residents. The “short-stay” population is largely in the NH for post-acute care after a hospitalization and requires a combination of skilled nursing care, rehabilitation therapy, adequate nutrition and hydration, and careful medical management in order to achieve a higher level of function and discharge home or to a less intensive care setting.

The underlying social contract implied by NH admission is quite different for each of the five groups of NH resident goals illustrated in the figure. Ideally, a NH should be able to provide what the name implies: high- quality nursing (and medical) care, in a home-like environment. In some

cases, access to treatment takes precedence over the living environment; in other circumstances, the environment may be the most critical element of care. Those admitted to a NH with the intent of active treatment and discharge home may be willing to accept a living situation akin to that of a hospital with the expectation that the benefit they receive from treatment will offset any discomfort or inconvenience. For terminally ill residents receiving palliative or hospice care, the living environment should be as flexible and supportive as possible. Efforts are directed toward supporting these residents to be comfortable and permitting them to enjoy, to the extent possible, their last days. For the other groups in the middle of this distribution, attention to making their living situation comfortable and providing active primary care are important. There is in fact considerable overlap in the clinical characteristics of the short and long-stay populations in terms of multimorbidity, complexity, medication issues, among others.

Some short-term patients become long-term residents because they do not have access to family or other caregiver support, limited availability of home-based service programs in their community, and the inability to pay for needed services and supports in the home versud spending down to qualify for Medicaid (which does cover the costs of institutional long-term care).

In addition to the different goals for care in the NH, several factors make the assessment and treatment of NH residents different from those in other settings (Table 16-2). Many of these factors relate to the process of care (see the following section). A fundamental difference in NH care compared to care in other settings is that medical evaluation and treatment is one component of an assessment and care-planning process involving staff from multiple disciplines. The integral involvement of certified nursing assistants (CNAs) in the development and implementation of care plans is crucial to high-quality NH care. Data on clinical conditions and their treatment are integrated with assessments of the functional, mental, nutritional, and behavioral status of the resident in order to develop a comprehensive database and individualized plan of care.

TABLE 16-2 ¦ FACTORS THAT DISTINGUISH ASSESSMENT AND TREATMENT IN THE NURSING HOME VS IN OTHER SETTINGS

Medical evaluation and clinical decision making for NH residents are complicated for several reasons. Unless the clinician has cared for the resident before NH admission, it may be difficult to access a comprehensive medical database that provides the background and context for their current status. Residents may be unable to relate their medical histories accurately or to describe their symptoms, and medical records are frequently unavailable or incomplete, especially for residents transferred between NHs and acute care hospitals. When acute changes in a condition occur, initial assessments are often performed by NH staff with limited skills and are communicated to clinicians (physicians, nurse practitioners, physician assistants) by telephone. Even when the diagnoses are known or strongly suspected, many diagnostic procedures and treatments among NH residents are associated with an unacceptably high risk–benefit ratio. For example, an imaging study may require sedation with its attendant risks; nitrates and other cardiovascular drugs may precipitate syncope or disabling falls in frail

ambulatory residents with baseline postural hypotension; and adequate control of blood sugar may be extremely difficult to achieve among diabetic residents with marginal or fluctuating nutritional intake. Further compounding these challenges is the inability of many NH residents to participate effectively in important decisions regarding their medical care. Their previously expressed wishes are often not known, and an appropriate or legal surrogate decision maker has often not been appointed. These issues are further discussed in Chapters 7, 10, 26, and 72.

Table 16-3 lists the most commonly encountered clinical disorders in the NH population. They represent a broad spectrum of chronic illnesses; neurologic, psychiatric, and behavioral disorders; and problems that are especially prevalent in frail older adults (eg, incontinence, falls, nutritional disorders, chronic pain syndromes). The management of many of the conditions listed in Table 16-3 is discussed in some detail in other chapters of this book.

TABLE 16-3 ¦ COMMON CLINICAL DISORDERS IN THE NURSING HOME POPULATION

The process of care in NHs is strongly influenced by numerous state and federal regulations, the highly interdisciplinary nature of NH residents’ clinical issues, and the training and skills of the staff that delivers most of the hands-on care. Federal rules and regulations contained in the Omnibus Budget Reconciliation Act of 1987 (OBRA, 1987) and implemented in 1991 place heavy emphasis on assessment through use of the Resident Assessment Instrument (RAI) and care planning as a means of achieving the highest practicable level of functioning for each resident. The minimum data set (MDS) 3.0, is the foundation of clinical assessment and care planning for individual residents. In addition to the MDS, each resident or responsible health care proxy should be assisted in articulating the goals for their NH care (ie, short-term rehabilitation and/or medical and nursing management of unstable clinical conditions with the goal of returning home; long-term care of chronic conditions; or palliative or hospice care). Detailed guidance for state and federal surveyors is available for several clinical care areas, such as unnecessary drugs and urinary incontinence. Failure to adhere to the clinical recommendations contained in the regulations and related surveyor guidance can result in citations and, in some instances, financial penalties or other enforcement actions. In addition, failure to manage clinical conditions appropriately puts the NH and clinicians at risk for legal action.

Physician involvement in NH care and the nature of medical assessment and treatment offered to NH residents may be limited by logistic and economic factors. Few physicians have offices based either inside the NH or in close proximity to it. Many physicians who do visit NHs care for relatively small numbers of residents, often in several different NHs. Many NHs, therefore, have numerous physicians who make rounds once or twice per month, who are not generally present to evaluate acute changes in resident status, and who attempt to assess these changes over the telephone. Practice patterns are shifting to a model of physician-nurse practitioner practices caring for large numbers of residents in several NHs. Such physician-nurse practitioner teams have been shown to improve care,

increase resident and family satisfaction, and reduce hospitalization rates. Value-based care programs such as intensive special needs plans (iSNPs) and bundled payments financially incentivize this approach to care. (iSNPs and other value-based programs are discussed in Chapter 19.)

Many NHs do not have ready availability of laboratory, radiologic, and pharmacy services with the capability of rapid response, further compounding the logistics of evaluating and treating acute changes in medical status. Thus, NH residents are often sent to hospital emergency rooms, where they are evaluated by personnel who are generally not familiar with their baseline status and who frequently lack training in the care of older adults.

Medicare and Medicaid reimbursement policies also dictate certain patterns of NH care. While physicians are required to visit NH residents only every 30 to 60 days, many residents require more frequent evaluation and monitoring of treatment, especially with the shorter acute care hospital stays brought about by the prospective payment system (PPS). While Medicare reimbursement for physician visits in NHs has improved, reimbursement for a routine visit is sometimes inadequate for the time that is required to provide good medical care in the NH, including travel to and from the NH; assessment and treatment planning for residents with multiple problems; communication with the resident, members of the interdisciplinary team and the resident’s family; and proper documentation in the medical record. Activities often essential to good care in the NH, such as attendance at interdisciplinary conferences, family meetings, complex assessments of decision-making capacity, and counseling residents and proxy decision makers on treatment plans, are often not reimbursable. The coronavirus pandemic has led to increased use of telehealth, which may facilitate accomplishing some of this direct care more efficiently (see below).

Medicare intermediaries sometimes restrict reimbursement for rehabilitative services for residents not covered under Part A skilled care, thus limiting treatment options for many residents. Although Medicaid programs vary considerably, many provide minimal coverage for ancillary services that are critical for optimal care and may restrict reimbursement for certain types of drugs that may be especially helpful for NH residents.

Amid these logistic and economic constraints, expectations for the care of NH residents are high. Table 16-4 outlines the various types of assessment generally recommended for the optimal care of NH residents. Physicians are responsible for completing an initial assessment within 72 hours of

admission and for monthly visits thereafter for the next 90 days. More frequent visits are often necessary for residents admitted on a Medicare Part A skilled nursing benefit. Licensed nurses assess new residents when they are admitted, on a daily basis, and summarize the status of each resident weekly. The nationally mandated MDS must be completed within 14 days of admission and updated when a major change in status occurs. Several sections of the MDS must be updated on a quarterly basis. The MDS is intended to assist NH staff in identifying important clinical problems that need care plans that include further evaluation, management, and monitoring. The MDS is also used as the basis for calculating daily reimbursement rates for residents on the Medicare Part A skilled benefit and as the basis for calculating various quality measures, including those on the NH Compare website and those used for the CMS Five-Star Quality Rating System.

TABLE 16-4 ¦ IMPORTANT ASPECTS OF VARIOUS TYPES OF ASSESSMENT IN THE NURSING HOME

The extent of involvement of other disciplines in the assessment and care-planning process varies depending on the residents’ conditions, the availability of various professionals, and state regulations. Representatives from nursing, social services, dietary, therapeutic recreation (activities), and rehabilitation therapy (physical, occupational, speech) participate in an

interdisciplinary care-planning meeting. Residents are generally discussed at this meeting within 2 weeks of admission and quarterly thereafter. Residents and family members or care partners are usually invited to participate in this initial care planning meeting. The product of these meetings is an interdisciplinary care plan that lists physical and psychosocial or behavioral conditions (eg, restricted mobility, incontinence, unstable gait, diminished food intake, poor social interaction, depression), goals set by or with the resident, approaches to achieving those goals, target dates for achieving the goals, and responsibilities for working toward the goals among the various disciplines. These care plans are important in supporting what matters to each resident and should be reviewed by the primary provider.

Better medical care of NH residents should lead to fewer exacerbations of chronic illnesses, iatrogenic conditions, and other adverse events, and hence lower use of emergency rooms and hospitals. Several strategies might improve the process of medical care delivered to NH residents. Four strategies are briefly described: (1) improved documentation practices; (2) a systematic approach to screening, health maintenance, and preventive practices; (3) collaborative care with nurse practitioners or physician assistants; and (4) practice guidelines and related quality improvement activities.

In addition to these strategies, strong leadership of a medical director (and in some cases associate medical director) who is appropriately trained and dedicated to improving the NH’s quality of medical care is essential in order to develop, implement, and monitor policies and procedures for medical services. Certification through the American Medical Directors Association (AMDA)–The Society for Post-Acute and Long-Term Care Medicine should be encouraged (https://paltc.org/). The medical director should set standards for medical care and serve as an example to the medical staff by caring for some of the residents in the NH. He/she should also be involved in various committees (eg, quality, infection control), and should try to involve interested medical staff in these committees, as well as in educational efforts through formal presentations, teaching rounds, and appropriate documentation procedures. Federal quality measures, as well as other quality indicators, developed through literature review and expert consensus should be used to track improvements in overall care in the NH setting. Medical directors should use these indicators and other approaches in their quality improvement programs and assisting the NH with meeting CMS requirements for Quality Assurance and Performance Improvement (“QAPI”).

Electronic health records (EHRs) specific for NHs are now widely available, and when used properly can greatly improve clinical documentation. Critical aspects of a NH resident’s health status should be recorded on a clinical “face sheet” of the medical record. Figure 16-2 shows

an example of the elements of and a format for such documentation. Additional standardized documentation should contain social information, such as individuals to contact at critical times (health care proxy, durable power of attorney for health care, legal guardian) and information about the resident’s treatment status in the event of acute illness (advance directives). These data are essential to the care of the resident and should be readily available in one place in the record, so that when emergencies arise, when medical consultants see the resident, or when members of the interdisciplinary team need an overall perspective, they are easy to locate. The face sheet should be sent to the hospital or other health care facilities when the resident is transferred. Time and effort are required in order to keep the face sheet updated. EHRs can facilitate incorporating the face sheet into a database and updating it periodically.

FIGURE 16-2. Example of a “face sheet” for a nursing home medical record. (Reproduced with permission from Kane RL, Ouslander J, Resnic B, et al. Essentials of Clinical Geriatrics. 8th ed. New York, NY: McGraw Hill; 2018.)

Many NHs currently use blended records with nursing and administrative documentation in the EHR. Handwritten medical documentation in progress notes for routine visits and assessments of acute changes is frequently scanty, uninformative, and/or illegible. Statements such as “stable” or “no change” are frequently the only documentation for routine visits. While time constraints may preclude extensive notes, certain standard information should be documented. The SOAP (subjective, objective, assessment, plan) format for charting routine notes is especially appropriate for NH residents (Table 16-5). Simple forms, flow sheets, or databases with word-processing capabilities can be used to enable physicians to efficiently produce legible, concise, comprehensive progress notes. Some EHRs include these capabilities.

TABLE 16-5 ¦ SOAP FORMAT FOR PROGRESS NOTES ON NURSING HOME RESIDENTS

Another area where medical documentation is often inadequate relates to the residents’ decision-making capacity and treatment preferences. These issues are discussed briefly at the end of this chapter as well as in Chapters 7,10, 26, and 72. In addition to placing critical information in a standardized

format in readily accessible locations, it is essential that physicians thoroughly and legibly document all discussions they have had with the resident, designated family member, legal guardian, or durable power of attorney for health care about these issues. Failure to do so may result not only in poor communication and inappropriate treatment, but also in substantial legal liability. Notes about these issues should not be removed from the EHR or the paper medical record and are ideally kept in a separate advance care planning section.

As NHs increasingly use health information technology, these recommendations for improved documentation can eventually be incorporated into the NH EHR. AMDA (https://paltc.org/) and the Interventions to Reduce Acute Care Transfers (INTERACT) quality improvement program (https://pathway-interact.com/) have examples of tools that can help improve documentation of clinical care in the NH and that can be integrated into EHRs. Documentation in the EHR using discrete items will facilitate using them in a relational database that can be used for quality improvement and research.

A second approach to improving medical care in NHs is developing and implementing selected screening, health maintenance, and preventive practices in order to delay or prevent exacerbations of chronic conditions. Table 16-6 lists examples of such practices. With few exceptions, the efficacy of these practices has not been well studied in the NH setting. In addition, not all the practices listed in this table are relevant for every NH resident. For example, some of the annual screening examinations are inappropriate for short-stay residents or for many long-stay residents with end-stage dementia or other life-limiting illness in which the time to benefit from the screening exceeds life expectancy. Thus, the practices outlined in Table 16-6 must be tailored to individual residents and must be creatively incorporated into routine care procedures as much as possible in order to be time-efficient, cost-effective, and reimbursable by Medicare. The Annual Wellness Visit is now supported by Medicare and can include individualized plans for screening and preventive health.

TABLE 16-6 ¦ SCREENING, HEALTH MAINTENANCE, AND PREVENTIVE PRACTICES IN THE NURSING HOME FOR LONG-

Advanced Practitioners (Nurse Practitioners, Clinical Specialists, and Physician Assistants)

A third strategy that may help improve care in NHs is partnering with or employing nurse practitioners and physician assistants. This approach appears to be cost-effective in both managed care and fee-for-service settings. These health professionals may be especially helpful in providing comprehensive care in the NH setting. Physician assistants and nurse practitioners can bill for services under fee-for-service Medicare and NHs and/or physician groups can hire them on a salaried basis. Nurse practitioners may have an especially helpful perspective in interacting with nursing staff about the non-medical aspects of care for NH residents. Nurse

practitioners and physician’s assistants can be very helpful in implementing some of the screening, monitoring, and preventive practices outlined in Table 16-6, and in communicating with interdisciplinary staff, residents, and family members or care partners at times when the physician is not available. One of the most appropriate roles for nurse practitioners and physician assistants is in the initial assessment of acute or subacute changes in resident condition. They can perform a focused history and physical examination and can order appropriate diagnostic studies. The INTERACT quality improvement program has several care paths for this purpose that address 10 of the most common conditions associated with hospital transfers, one of which is shown in Figure 16-3. Use of such care paths and other tools available through the INTERACT website (https://pathway-interact.com/), as well as through AMDA, enables onsite assessment of acute change, detection and treatment of new problems early in their course, more appropriate utilization of acute care hospital emergency rooms, and rapid identification of residents who need to be hospitalized.

Take Vi?al Signs

Temperature·
BP, putse, ap?ca? HR (ff ??u?se lrregvlafJ
Fi.esptialions
Oxygen saiuralion
Flnger sUck g?ucose ?dlabetks)

Symptoms or Lower Resp,iratory lnf,ection Noted*

+ New or worsened cough

New or lncreased spulum produotion New or 1?orsen?ng sho?ness ol breath?
Chest paln Wllh inspiraflon orcoughing
New o.r increased flndings 011 ?ung e?am (rares, wheezes)

Consider Contacting MD/NP/PA for orders (for further Nursin·g evaluation and management)

, .. Reler also 10 ?!/Jer INTERACT care parhs as fndicared by syrnpt?ms rmd slg?s

Clinical Practice Guidelines and Quality Improvement Activities Several clinical practice guidelines relevant to NH care have been

developed by AMDA (https://paltc.org/). In addition, quality indicators for a number of conditions have been developed. While these guidelines and quality indicators are largely based on expert opinion rather than on controlled clinical trials, they are helpful as a basis for standards of practice that will improve care. Implementation and maintenance of clinical practice guidelines can be challenging in NHs, as it is in other practice settings. NHs are required to have an ongoing quality assessment and assurance (QAA) committee, and as mentioned above, federal regulations now require an active Quality Assurance Performance Improvement (QAPI) program.

Principles of continuous quality improvement (CQI) and rapid-cycle performance improvement projects (PIPs) engage direct care staff to monitor objective outcomes (such as the frequency of falls, severity of incontinence, adverse drug reactions, and skin problems) and to identify work processes that can be modified to continuously improve these outcomes. NH administrators, directors of nursing, and medical directors must create an environment that provides incentives for ongoing quality activities in order to maintain these programs over time. The Medicare Quality Improvement Organization/Quality Innovation Network (QIO/QIN) program as well as AMDA and its journal have substantial free or low-cost resources for assisting NH providers with quality improvement initiatives. In addition, CMS provides educational resources and tools for NHs to help them meet QAPI requirements (https://www.cms.gov/Medicare/Provider-Enrollment- and-Certification/QAPI/qapidefinition).

As a result of the increasing acuity and clinical complexity of the NH resident population, transfer back and forth between the NH and one or more acute care hospitals is common. About one in five NH residents admitted from a hospital are readmitted to the hospital within 30 days. Transfer to an acute care hospital is often a disruptive process for a NH resident, and is

especially hazardous for NH residents with dementia. In addition to the effects of the acute illness, NH residents are subject to acute mental status changes and a myriad of potential iatrogenic problems. The most prevalent of these iatrogenic problems are related to immobility, including deconditioning with resulting difficulty regaining ambulation and/or transfer capabilities, hospital-acquired infections, incontinence and catheter use, polypharmacy and adverse drug effects, delirium, and the development of pressure ulcers.

Because of the risks of acute care hospitalization, the decision to transfer a resident to the emergency room or hospitalize a resident must carefully balance a number of factors. A variety of medical, administrative, logistic, economic, and ethical issues can influence decisions to hospitalize NH residents. Decisions regarding hospitalization often boil down to the capabilities of medical care providers and the NH staff to provide services in the NH, the preferences of the resident and, when indicated, the family, and the logistic and administrative arrangements for hospital care. If, for example, the NH staff has been trained and has the personnel to institute intravenous therapy without detracting from the care of other residents, or if it has arranged for an outside agency to oversee intravenous therapy and there is a nurse practitioner or physician’s assistant to perform follow-up assessments, the resident with an acute infection who is otherwise stable may best be managed in the NH. Better advance care planning and advance directive use can also help to avoid unnecessary hospitalization of NH residents when the palliative or hospice care may be more appropriate than hospital transfer.

AMDA has developed a clinical practice guideline and related tools on care transitions (https://paltc.org/topic/transitions-care). The INTERACT program includes educational resources and tools that have been developed and have shown promise in reducing unnecessary hospital transfers. The INTERACT program uses several basic strategies to improve the management of acute changes in condition and prevent unnecessary hospital transfers including: (1) proactive identification of conditions before they become severe enough to require hospital care (eg, dehydration, delirium);

(2) management of some conditions (eg, pneumonia, congestive heart failure) without transfer when safe and feasible; (3) improving advance care planning in order to consider palliative or comfort care as an alternative when the risks of hospitalization may outweigh the benefits; (4) improved documentation practices; (5) improved communication within the NH and

between the NH and the hospital; and (6) embedding these strategies within everyday care, including within EHRs.

Ethical issues arise as much or more in the day-to-day care of NH residents as in care in any other setting. These issues are discussed in Chapter 72.

Table 16-7 outlines several common ethical dilemmas that occur in the NH. Although most attention has been directed toward those with limited ability to express their preferences, important daily ethical dilemmas also face those who are capable of decision-making. These more subtle problems are easily overlooked. Physicians, nurse practitioners, and physician assistants providing primary care must serve as strong advocates for the autonomy and quality of life for NH residents.

TABLE 16-7 ¦ COMMON ETHICAL ISSUES IN THE NURSING HOMEA

hoices i11 ma??y a1·eas are li??ited in most n1u-si??g h.0•111es (eg) n?.ealtiroe.s. sleep?ng h,0,11:rs )?

Many nursing l1,01ne res'dents are i? ,capa ble 01· are questio,11ab?y capable ,of partic' pating in decisio,ns abo,ut t,]1eir care

There are 110 standa1·d metl1od ofas.sess ing dec1s1on-makin.gcapacity in this population

Fam"ly ?nemb •s mayb ·n conflic·t, h.ave hidden agenda , 0·1· b incapable ofo1· unwilli1 g to make deci.sions

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nu- ing 1-ome re ·a 11ts) qua]ity-ofiife A ·ang .f opti,011 ?nu ·t b,.. consid ·-ed,

··z:a:t" ?, ·t"eat?n.nt of pecific co1 di ions (eg) infection) •n ,h nurs.ing ho?n without h,ospitalization" n·t 1·al fe-din·g) co:rufort>01· suppo,rtive care or1ly

NHs care for a high concentration of individuals who are unable or are questionably capable of participating in decisions concerning their current and future health care. Among these same individuals, functional disabilities and terminal illnesses are prevalent. Thus, questions regarding individual autonomy, decision-making capacity, surrogate decision makers, and the intensity of treatment arise on a daily basis. These questions are both troublesome and complex and must be managed in a straightforward and systematic manner in order to provide optimal care to NH residents within the context of ethical principles and state and federal laws. NHs should be encouraged to develop their own ethics committees or to participate in a local existing committee within another organization. Ethics committees can be helpful in educating staff; developing, implementing, and monitoring policies and procedures; and providing consultation in difficult cases.

The COVID-19 pandemic has had profound effects on NHs in the United States that have already and continue to work toward major changes over the coming years. In addition to exposing the fact that NHs were for the most part unprepared to deal with a pandemic of this nature, it has shed light on the need to restructure NH care and its financing to meet the needs of a growing vulnerable population that will require short-term or long-term care over the next several decades. Many NHs have suffered devastating COVID-19 outbreaks that led to high mortality rates among NH residents and staff as well. Many NHs did not have adequate personal protective equipment (PPE) and testing capability throughout the first months of the pandemic, and some still do not, especially in the face of increasing viral positivity rates and influenza season. Staffing shortages have been severe in many NHs because a substantial number of staff have had positive viral tests and/or close exposure to an infected individual and have to undergo a minimum 14-day quarantine period off work. The federal government has promulgated waivers, guidance, and new regulations that have been helpful. It has also provided considerable financial relief for NHs, but it was not enough to support all the PPE and viral testing essential for care.

Some of the key issues that may have an enduring impact on NH care in the United States include:

research, educational interventions, and epidemiological studies to continue to develop the evidence base for improving NH care with respect to pandemics as well as other areas of care and support.

Dr. Ouslander is a full-time FAU employee and has received support through FAU to conduct research evaluating the INTERACT program from the National Institutes of Health, the Centers for Medicare and Medicaid Services, the Commonwealth Fund, the Retirement Research Foundation, PointClickCare, Medline Industries, and PatientOrderSets (now Think Research). Dr. Ouslander is a paid medical advisor to Pathway Health which holds the exclusive license from FAU for training and sublicensing of INTERACT, and he and his wife receive royalties related to INTERACT. Works on projects related to INTERACT are subject to terms of Conflicts of Interest Management plans developed and approved by the FAU Division of Research Financial Conflict of Interest Committee.

Alice Bonner is an Adjunct Faculty at the Johns Hopkins University School of Nursing and Director of Strategic Partnerships for the CAPABLE Program. She is also Senior Advisor for Aging at the Institute for Healthcare Improvement (IHI). From 2011 to 2013, Bonner was the Director of the CMS Division of Nursing Homes.

American Medical Directors Association. Transitions of Care in the Long- Term Care Continuum Clinical Practice Guideline. Columbia, MD: AMDA; 2010.

American Medical Directors Association. Health Maintenance in the Long- Term Care Setting Clinical Practice Guideline. Columbia, MD: AMDA; 2012.

Department of Health and Human Services Office of the Inspector General. Adverse Events in Skilled Nursing Facilities: National Incidence among Medicare Beneficiaries. February, 2014. OEI-06-11-00370.

Jump RLP, Crnich CJ, Mody L, et al. Infectious diseases in older adults in long-term care facilities: update on approach to diagnosis and management. J Am Geriatr Soc. 2018;66:789–803.

Mor V. Defining and measuring quality outcomes in long-term care. J Am Med Dir Assoc. 2006;7:532–540.

Morley J, Tolson D, Ouslander J, Vellas B. Nursing Home Care: A Core Curriculum for the International Association for Gerontology and Geriatrics. New York, NY: McGraw Hill; 2013.

Ouslander JG, Berenson RA. Reducing unnecessary hospitalizations of NH residents. N Engl J Med. 2011;365: 1165–1167.

Ouslander JG, Bonner A, Herndon L, Shutes J. The INTERACT quality improvement program: an overview for medical directors and primary care clinicians in long-term care. J Am Med Dir Assoc. 2014;15:162– 170.

Ouslander JG, Naharci I, Engstrom G, et al. Root cause analyses of transfers of skilled nursing facility patients to acute hospitals: lessons learned for reducing unnecessary hospitalizations. J Am Med Dir Assn.

Ouslander JG, Grabowski DC. Rehabbed to death reframed: in response to “rehabbed to death: breaking the cycle”. J Am Geriatr Soc.

Ouslander JG, Grabowski DC. COVID-19 in nursing homes: calming the perfect storm. J Am Geriatr Soc. 2019;68:2153–2162.

Saliba D, Schnelle JF. Indicators of the quality of nursing home residential care. J Am Geriatr Soc. 2002;50: 1421–1430.

Saliba D, Solomon D, Rubenstein L, et al. Feasibility of quality indicators for the management of geriatric syndromes in nursing home residents. J Am Med Dir Assoc. 2005;6:S50–S59.

Saliba D, Solomon D, Rubenstein L, et al. Quality indicators for the management of medical conditions in nursing home residents. J Am Med Dir Assoc. 2004;5: 297–309.

Zarowitz B, Resnick B, Ouslander JG. Quality clinical care in nursing facilities. J Am Med Dir Assn. 2018;19: 833–839.

Interventions to Reduce Acute Care Transfers (INTERACT). https://pathway-interact.com/. Accessed June 1, 2021.

Seventy percent of people turning age 65 will need some type of long-term care (LTC) services in their lifetime. While some of those people will be cared for in a nursing home, the majority will choose to remain in the community and require services to help them stay in their homes. These home-based care services come in the form of two general categories— community-based long-term services and support (LTSS) and home-based medical care services. Unfortunately, no coherent national policy drives LTSS in the United States, which leaves a “system” that is difficult to access, bewildering to navigate, unable to fully meet the needs of many patients, and exacerbates health disparities. Much of what is done to meet these needs is provided by unpaid family caregivers at great personal and economic cost.

Among the many long-term sequelae of the COVID-19 pandemic, one that is most likely to persist is the preference for non-facility-based health care delivery. This preference, as well as the COVID-19-induced acceleration of telehealth approaches, is likely to create even greater demand for home- based services of all types in the future. This chapter addresses LTSS and home-based medical care for older adults in the United States. We outline the semantic challenges in understanding the scope and nature of LTSS and the heterogeneity of LTSS and home-based medical care models that comprise it; describe who receives, provides, and pays for it; and review the evidence for its effectiveness. We also discuss important public policy issues and identify emerging innovations and trends in this arena.

Community-based long-term services and support (LTSS) and home-based medical care cover the spectrum of home-based care that exists to support and care for older adults living at home. The term “community-based long- term services and support” overlaps with several other terms in the medical and social sciences literature, including home care, personal care services, home- and community-based services, home visits, and others. In general, these terms refer to non-physician, nursing, personal care, or social services provided to older persons with an explicit goal of filling unmet needs or maintaining them in the community. Unpaid family members or friends provide a majority of this care, sometimes with support from a variety of paid formal caregivers. Home-based medical care includes models that involve direct care by a physician or advanced practice provider (nurse practitioner or physician assistant). These may include longitudinal care models, such as home-based primary care, or may include episodic care, such as preventive home-based geriatric assessment visits, home-based rehabilitation, and hospital at home (HaH). LTSS and home-based medical care often overlap to such an extent that important aspects of a given intervention are not accurately reflected in a single label. For example, a program in which an interdisciplinary team provides comprehensive geriatric assessment followed by home-based primary care, inpatient management as needed, and continuing longitudinal care after hospital discharge does not fit neatly into any one category. Several forms of LTSS integrate housing arrangements with personal care and home-based medical care, further blurring the distinction between community-based and institutional LTSS. Table 17-1 depicts the heterogeneity and scope of services and settings that fall under the rubric of LTSS.

TABLE 17-1 ¦ LONG-TERM SERVICES AND SUPPORTS AND HOME-BASED MEDICAL CARE MODELS

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Home health care encompasses a spectrum of care including long-term social services, informal and formal paid care in the home, and skilled home health care. Home and community-based services usually refers to LTSS provided under the Medicaid program. Informal care refers to services provided by unpaid caregivers, most commonly female family members. The estimated 48 million informal caregivers in the United States provide the majority of all home care and LTSS at an estimated economic value of $470 billion. Formal paid care includes paid home health aides for personal care services in the home (bathing, dressing, etc) and typically is covered via private pay by the patient, though also may be covered through state Medicaid waiver programs or Department of Aging Social Services programs. Paid care in assisted living facilities (ALFs), sheltered housing, and group homes is variable and may include medication administration and monitoring of vital signs as well as access to physicians when needed, such as domiciliary care visits or a clinic housed within a senior apartment building. Skilled home health care refers to formal services delivered by professional providers, such as nurses or physical, occupational, or speech therapists. Medicare certifies and reimburses home health care agencies (HHAs) to provide this type of care when a patient is homebound and has a skilled need (see “Who Provides and Pays for LTSS and Home-Based Medical Care” later in the chapter). HHAs may also provide formal personal care services (bathing, dressing, etc) under the Medicare home health care benefit while a patient is receiving skilled care. Referrals for Medicare skilled home health care are placed for patients who have a skilled need, such as physical therapy or nursing care, and may originate from the hospital, rehabilitation setting, or from outpatient or home-based primary care. For example, an older patient who suffers an acute exacerbation of chronic obstructive pulmonary disease may spend several days in bed (at home or in the hospital), and may need nursing to monitor her respiratory status and physical therapy to help her regain her baseline functional mobility. It is important to note that the effectiveness of skilled home care often relies on services provided by an informal caregiver who, if available, can help

implement a home exercise program, clean and dress pressure ulcers, or bathe, dress, and toilet a dependent patient.

Models of home-based medical care include a spectrum of options, including both longitudinal and episodic care options: home-based primary care, home-based primary care co-management, home-based integrated medical and social care, home-based palliative care and hospice care, preventive home-based geriatric assessment, rehabilitation at home, and HaH. Home-based primary care, in which physicians, nurse practitioners, and physician assistants provide ongoing longitudinal medical care at home, can play an important role in providing access to routine and urgent care for older adults who have difficulty getting to a medical office. Home-based primary care programs have been increasing in prevalence in recent years and have been shown to be effective (see Table 17-2 later in this chapter). In 2013, approximately 5000 individual health care providers made 1.7 million home visits in the United States, accounting for 70% of home-based medical visits. Some models include home-based primary care as part of their continuum of care, such as the Program of All-Inclusive Care for the Elderly (PACE), which relies heavily on a “day health center” in which dually eligible (ie, Medicare and Medicaid eligible) nursing home–eligible participants receive comprehensive medical, hygienic, social, and rehabilitative care. Home-based primary care co-management models involve the use of an interdisciplinary care team to help care for patients with complex needs in collaboration with a patient’s primary care provider. Home-based integrated medical and social care models provide integrated medical and social services for patients with significant medical, behavioral health, and social needs with an interdisciplinary team that typically includes behavioral health specialists. Home-based palliative care may be embedded within home-based primary care models, or may be provided by hospice agencies as a continuum of care prior to home hospice care. Home hospice care provides end-of-life care to patients within the last 6 months of life, with home-based support focused on comfort care. Hospital-at-home is a care model that provides hospital-level care in a patient’s home as a substitute for an acute hospital admission that has been shown to be associated with better care quality and lower costs than typical hospital care. Rehabilitation-at-home provides subacute rehabilitation at home posthospitalization.

TABLE 17-2 ¦ EVIDENCE FOR EFFECTIVENESS OF LONG- TERM SERVICES AND SUPPORTS (LTSS) AND HOME-BASED MEDICAL CARE (HBMC) MODELS

Other home-based approaches offer one-time visits or assessments or care focused on specific diseases or conditions. Preventive home visits and home-based geriatric assessment typically aim to identify older adults in the community who have hidden risks for developing illness or functional decline, and modify those risks to prevent poor outcomes. These visits may be provided as part of Medicare Advantage programs, such as through Medicare Annual Wellness Visits provided at home, or may be done by community health workers as a geriatric assessment visit to assess risk.

Home-based disease management programs target patients known to have specific diseases or conditions that require significant care coordination, such as diabetes or heart failure, for formal support in managing those conditions, with the goal of delaying disease progression and avoiding hospitalization. Community paramedicine programs use emergency medical services to deliver hospital triage or assessment. They typically target high utilizers of emergency department or hospital services, or may work collaboratively with home-based primary care programs. Home-based urgent care programs provide urgent care options, sometimes through apps that help locate a local home-based care provider or to connect via telemedicine; these are typically urgent, one-time visits and not longitudinal, ongoing care. Additional short-term home-based interventions have been shown more recently to support older adults who continue to live in their homes.

Community Aging in Place, Advancing Better Living for Elders (CAPABLE) is an intervention that involves an interprofessional team (occupational therapist, nurse, and handyperson) to help patients achieve goals they set and has been shown to reduce disability as well as costs for inpatient care and

long-term support services. Maximizing Independence (MIND) at Home is a home-based dementia care coordination program that uses community health workers as a liaison between patients with dementia and a team with dementia expertise, and also has been shown to reduce costs of inpatient care and LTSS.

Still other forms of LTSS provide care outside the home or may require older adults to relocate to a new living situation. Adult day care generally includes transportation to a day care center, and can provide both structured social activities and basic medical monitoring and treatment. For patients who cannot continue to live in their own homes, assisted living, sheltered housing (also known as senior apartments), adult foster care, and group homes all provide varying levels of functional assistance and access to some medical services. Continuing care retirement communities (CCRCs), as the name suggests, are self-contained organizations that allow people to move within the community to increasing levels of care as their needs dictate. At one end of the continuing care spectrum, a fully independent older adult lives in a single-family home or apartment, but over time may transition first to an assisted-living apartment, then to the skilled nursing facility within the same CCRC. There are several variations of this model, but most charge an entrance and monthly fee that provides lifelong care in the event that the participant develops some kind of functional impairment.

This array of models can be framed as a quasi-continuum of care services for older adults, as shown in Figure 17-1. While some forms of home-based care are designed to address the needs of older adults through a variety of health or disease states, such as home health care, CCRCs, or post- acute disease management programs, others are targeted to specific populations based on levels of impairment or disability, such as home-based primary care or PACE. Again, many patients and programs do not fit neatly into a single category and patients do not usually move across the continuum in a straight line, as the use of services depends not only on the fit between the needs of an older adult and the care model, but also on the preferences of older adults and local availability of care models. For example, skilled home health care may be used by a healthy older adult after elective joint replacement surgery or a frail chronically ill patient recovering from a recent episode of community-acquired pneumonia treated at home by a home-based primary care program. However, the concept of a continuum is a useful construct for organizing categories of LTSS and home-based medical care.

FIGURE 17-1. Home-based care delivery models across the continuum of care for older adults.

Health maintenance strategies such as preventive home visits and geriatric assessment tend to target patients who are relatively robust and functionally independent, while PACE and home-based primary care address the needs of patients who are more frail and impaired. CCRCs explicitly transition patients from the robust state through functional decline. Post-acute home health care, home-based primary care, rehabilitation at home and HaH may be used by both robust and frail older adults in specific circumstances, but the primary intended users of most LTSS and home-based medical care remain those who have chronic and complex medical illness accompanied by some level of functional disability, and thus require care for a prolonged or even indefinite time. The likelihood of receiving formal care is generally lower for men, people of color, married individuals, those with lower socioeconomic status, and those who are less dependent for assistance with activities and instrumental activities of daily living (ADLs), but one particular diagnosis profoundly affects these demographics. In the 2015 National Health and Aging Trends Study (NHATS), 25% of patients with dementia and 48% of patient with advanced dementia received paid care,

and the likelihood of paid care increased for men, unmarried patients, those on Medicaid (lower socioeconomic status), and those with more functional impairment. The racial disparities documented in outpatient offices and hospitals are also present in LTSS, with a 2017 systematic review demonstrating that minority of patients consistently had more adverse events, less functional improvement, and worse patient experiences than White patients.

The role of unpaid informal caregivers cannot be overemphasized. The work they perform is not directly reimbursed or financially rewarded by the health care system. The indirect costs are enormous when lost wages, lost productivity, health care costs related to caregiver burden, and future social insurance losses are calculated for caregivers who may sacrifice paid employment to provide informal care for a parent or other relative. For formal care, the provider varies with the type of care. In the most common model of skilled home health care, an HHA certified to provide care under Medicare reimbursement rules employs nurses, therapists, aides, and social workers, and assigns them to individual patient cases. A physician must certify that the patient is homebound and has a skilled need in order for a Medicare-certified HHA to provide care for a 60-day “certification period.” This certification must be based on a face-to-face encounter by the physician or associated nurse practitioner within 90 days before or 30 days after the start date of home health services. By definition, a skilled need requires care that is part-time, intermittent, and must be provided by a person with special training (eg, a nurse or therapist). Personal care assistance with ADLs such as bathing and dressing is covered during the certification period, but Medicare does not pay for it in the absence of a skilled need. In 2021, Medicare implemented the Patient Driven Groupings Model (PDGM) to pay for home health care. Under this model, reimbursements are based on a combination of four categories: the patient’s location in the 14 days before the start of home care (“admission source”), the admitting diagnosis (“clinical grouping”), the patient’s comorbidities (“comorbidity adjustment”), and the patient’s functional level. Functional level is determined using the Outcome and Assessment Information Set (OASIS).

These four categories are then used to assign the patient to one of 432 “payment groups” that determine the PDGM reimbursement the agency will receive for the 60-day certification period. The certification period is divided into two 30-day payment units, and each 30-day period has a separate admission source determination, based on the patient’s health care setting in the 14 days before the start of that period. Periods with “institutional” admission sources, when the patient has been in an acute or post-acute facility within the 14 days prior to the start of care, are reimbursed at a higher rate than periods with “community” admission sources, when there is no acute or post-acute stay in the preceding 14 days. A patient can be “recertified” for multiple 60-day periods as long as a skilled need exists. The settlement of the Jimmo v Sebelius case, in 2013, clarified that Medicare reimbursement for skilled home health services is allowed for people whose potential to improve may be limited, as long as there is a skilled need focused on preventing further deterioration or maintaining current level of function. LTSS can also be privately purchased by the care recipients. Additionally, a “consumer-directed” or “cash and counseling” model allows selected patients to choose, train, and pay their personal care providers directly with designated state funds (usually from Medicaid programs), instead of using an agency as an intermediary. In these programs, care providers can be family members or other previously unpaid caregivers. This model has had positive results, showing increased patient empowerment and satisfaction, and fewer unmet needs, although unmet needs persist, and new needs emerge as patients are required to function as employers.

Interdisciplinary teams are critical in coordinating and delivering care in home-based medical care, including skilled home health care ordered by physicians, home-based geriatric assessment, PACE, home-based primary care, and HaH (see Chapter 14). Such teams typically include physicians or advanced practice providers, although the provider’s role may vary in different settings depending on the medical complexity of the patient and the setting. For example, in PACE, the provider delivers primary care services, manages acute illness during hospitalization, and coordinates the activities of the interdisciplinary team, often in the patient’s home. In rehabilitation at home, the interdisciplinary team drives most of the management with a focus on restoring function and following up medical issues. In hospital-at-home interventions, the provider actively manages acute illness at home, so that medical house calls (in-person and/or virtual) complemented by close

coordination of the interdisciplinary team are crucial in this setting. Improvements in Medicare reimbursement for home-based primary care and demonstrations of cost savings with targeted home-based services have contributed to a recent growth in academic and private sector home-based medical care programs. Emerging co-management models, in which companies provide coordinated and comprehensive telemedicine services, in-person assessments from medical providers, and/or social services, may reduce unnecessary hospitalization, lower costs, and improve health outcomes and patient satisfaction. Commercial insurers, managed care organizations, and health systems at risk for total costs for their populations are currently the main drivers developing these models.

Other forms of home-based care rely less on medical providers and more on specialized nurses or trained lay visitors. Disease management, post-acute home health care, and medical day care are often based on protocols driven by nurses. In transitional care interventions, specially trained registered nurses (RNs) provide a combination of telephone or video support, remote

in-home monitoring of parameters such as weight, blood pressure, and pulse oximetry, and communication with primary care providers to reduce the risk of hospital readmission during the transition from acute care to home. Home- based geriatric assessment is usually performed by geriatric nurses or nurse practitioners and then discussed as needed with physicians, while preventive home visits have been successful in using “health visitors,” or specially trained community health workers, in screening for health risks. The CAPABLE program is a time-limited intervention of nurse, occupational therapist, and handypersons targeted at community-dwelling older adults with functional impairment with the goal of improving their functional status. A small number of older adults carry privately funded long-term care (LTC) insurance, and in recent years, some businesses have added this option to their employees’ benefit packages. Older adults with higher LTSS needs have higher Medicare and out-of-pocket costs, increased credit card debt attributable to health care expenses, and more difficulty paying for food, rent, utilities, medications, and medical care. Ultimately, many of these people exhaust their retirement savings and home equity to pay for LTSS, becoming eligible for Medicaid through this “spend-down” process.

Studies of home-based care can be challenging to interpret because of the semantic difficulties outlined above, the heterogeneity of home care interventions, difficulties in controlling for severity of disability or morbidity burden of patients, patient attrition issues, changes in regulation over time, and examination of a disparate range of outcome measures.

However, it is clear that the evidence base for home-based care has becoming increasing robust over the recent years. Key studies and their findings are summarized in Table 17-2. We discuss the current evidence by separating home-based medical care models into two broad categories by the time frames over which they provide care: (1) longitudinal models that provide care and follow patients over an extended period of time, and (2) episodic models that provide care that is limited to a single incidence or time-limited episode of care. Figure 17-1 arrays the services and models along the axes of care from nonmedical (little or no physician involvement) to medical (more physician and nurse practitioner involvement) and from chronic/longitudinal models (those that may follow patients for months to years with no intent to discharge a patient) to models that are acute/episodic (short-term with a plan to discharge the patient).

As described above, home-based primary care provides longitudinal primary care to homebound older adults with multiple chronic conditions and functional impairments who commonly face socioeconomic challenges.

Medical care is a core component and interdisciplinary care is commonly provided. Systematic reviews demonstrate reductions in emergency department visits, hospitalizations, LTC admissions, and costs of care, and improvements in patient and caregiver quality of life and satisfaction with care. Home-based primary care co-management models have emerged in the recent years and provide wraparound care to high-need, high-cost populations often in risk arrangements between providers of such care and payers who seek to provide value-based care to this population. In collaboration with the primary care provider an interdisciplinary team addresses the patient’s complex care needs. Randomized controlled trials of some models show reduced health care utilization and increased care coordination and patient/caregiver satisfaction. Home-based integrated medical/social care models provide multifaceted, longitudinal, wraparound medical and social services for high-need high-cost patients with complex

medical, behavioral health, and social needs within interdisciplinary care team that often includes behavioral health specialists. Reimbursement is usually through shared savings mechanisms. Observational and case-control studies demonstrate lower health care utilization and institutionalization and higher patient satisfaction. Home-based palliative care provides interdisciplinary, longitudinal or episodic, specialist palliative care in the home to patients with serious illnesses. Providers usually focus on clarifying goals of care, symptom management of patients and families. There is evidence for improved quality of life and reduction in health care utilization and costs. The comprehensive management strategies of the PACE programs are effective at reducing institutionalization of at-risk patients.

Transitional care focuses on patients at high risk of poor outcomes during the transitions from hospital back to home. Transitional care focuses on care coordination, education, follow-up, and medication management. Meta- analyses and systematic reviews demonstrate improved outcomes including reductions in mortality and reductions in emergency department visits and hospital readmissions in the 30 days after hospital discharge. Mobile Integrated Health–Community Paramedicine is an episodic care delivery model that has emerged recently. The model targets high utilizers of emergency department and hospital services via two main models: (1) urgent, unplanned pre-hospital triage and care to avoid unnecessary emergency department or hospital use; and (2) non-urgent, planned posthospital discharge care to prevent readmissions. Early evidence demonstrates reduced utilization and improved patient satisfaction. HaH provides hospital-level care in a patient’s home as a substitute for care provided in the traditional acute care hospital. Substitution HaH admits patients to their home directly from the emergency department. Transfer HaH admits patients who require ongoing hospital-level care from the traditional hospital to their home. Reimbursement exists mainly through Medicare Advantage and Veterans Affairs health systems currently. During the COVID- 19 pandemic, the Centers for Medicare and Medicaid Services provided a waiver to pay hospital-level reimbursement for HaH care for fee-for-service Medicare beneficiaries. HaH care has been demonstrated in multiple randomized controlled trials, systematic reviews, and meta-analyses to be associated with lower costs, lower complications and mortality, and

improved patient/caregiver satisfaction and experience. Rehabilitation at Home is an emerging care delivery model that provides episodic care delivered at home to people requiring care at time of hospital discharge that would otherwise would be provided in a skilled nursing facility. Care is provided by an interdisciplinary care team with skilled therapists supported by doctor, nurse, social worker, and other team members as needed. Early evidence suggests good functional outcomes and lower costs of care.

CAPABLE, described earlier, has demonstrated improvements in ability to perform ADLs and to reduce hospital utilization and costs of care with decreased annual health care costs to Medicaid by about $10,000 per patient, with a 5-month intervention at a cost of $2,825 per patient. It has been adopted by several state Medicaid plans.

As Table 17-2 indicates, an extensive home care literature includes a wide variety of interventions and target populations. While this heterogeneity creates significant difficulty in drawing conclusions about the effectiveness and cost-effectiveness of home care, the overall body of evidence suggests that specific models when appropriately targeted are probably effective.

This issue of targeting care to appropriate patient populations is a major determinant of the cost-effectiveness of specific interventions. A related factor that complicates discussions of cost-effectiveness is the notion of paid care inappropriately substituting for informal care at a cost to society, or the “moral hazard” or “woodwork” effect. In theory, if LTSS are made widely available, functionally impaired patients will “come out of the woodwork” to utilize them, even though most of these patients would never enter an institution even without using LTSS. Thus, the cost of providing care will overwhelm the potential savings of avoiding institutionalization. Targeting services to patients who are at high risk for LTC placement is generally accepted as an important way to optimize cost-effectiveness, but no practical, precise, and accurate targeting tools have been developed and tested. This is because the need for LTC placement is multifactorial, and a highly person-centered decision. Greater state expenditures on LTSS are associated with lower rates of LTC placement of older adults who do not have significant impairment in “late-loss” ADLs (bed mobility, toileting, transferring, and eating). Cost-effectiveness also depends on the economic features of the health systems in which various forms of LTSS have been studied; findings from European programs in which the government is the payer for LTSS, institutional LTC, and acute care are difficult to apply to the

United States fee-for-service environment with multiple public and private payers and complex cost-shifting pressures. The evidence base for home- based medical care models more clearly demonstrates effectiveness.

Telemedicine and virtual care, accelerated by the COVID-19 pandemic, has emerged as a major innovation in health service delivery and has the potential to accelerate the development of home-based care for older adults and for the general population. Until the COVID-19 pandemic, telemedicine was used at some scale mostly in rural populations or in systems with particular needs for it such as the Veterans Affairs health system for certain types of specialized care. Use cases such as dermatology, ophthalmology, and wound care have been widely studied in small clinical trials and appear to allow accurate diagnosis and management through both real-time interactions and “store-and-forward” applications in which clinical data including video images are collected and stored for later review by a clinician. In addition, they have been used in disease management interventions to enhance communication between patients and providers and facilitate closer monitoring of overall health when conducted in settings with specialized equipment and dedicated staff. Although the evidence is limited by methodologic variability, lack of comparison with in-person evaluation, and absence of clinical outcome measures, a 2019 systematic review by the Agency for Healthcare Research and Quality (AHRQ) concluded that in some situations, the results of telemedicine vary by setting and condition and that remote consultations for outpatient care likely improve access and clinical outcomes.

In the early phases of the COVID-19 pandemic, ambulatory care came to a grinding halt. The Centers for Medicare and Medicaid Services (CMS) provided regulatory relief in their “Hospital Without Walls” regulatory guidance that allowed for reimbursement of non-in-person outpatient visits to help patients maintain care with their outpatient and home-based primary care and specialty physicians. Health systems, ambulatory, and home-based medical care practices implemented virtual visits at a scale and speed thought impossible. In addition, the CMS provided a hospital-based waiver to provide a hospital diagnosis-related group payment for fee-for-service Medicare beneficiaries for hospital at home care.

Point-of-care diagnostic and therapeutic technology including electrocardiography, ultrasound, blood analysis, and intravenous treatment holds promise for health care delivery in home care and house calls.

Wireless telephone and Internet applications that allow secure, high-speed broadband connections between portable electronic medical records (EMR) systems and acute care or office information systems can provide safe and seamless continuity of care with immediate data access and entry for providers caring for complex older patients with multiple medical issues, medications, sites of care, and consultants.

Remote patient monitoring on intermittent and continuous basis is now feasible. It has been used in multiple contexts including hospital discharges, specific disease management programs for conditions such as heart failure, COPD, home-based dialysis, Parkinson disease, postoperative care, diabetes, blood pressure management, and others. Few randomized controlled trials have been conducted. Wireless and smartphone applications are the most commonly used strategies. Models also commonly employ teleconsultation approaches.

Several emerging trends in health care and the growing recognition of home- based care and the population it serves are driving innovation in health service delivery that will expand significantly for years to come. There is a growing recognition of the role of social, cognitive, and functional risk factors, as well as that a significant portion of health care spending on frail older adult populations are preventable. Further, there is recognition that home-based care can address these issues, as well as provide acute on primary geriatric medical care, in ways that facility-based care cannot.

The Affordable Care Act established the Medicare Shared Savings Program to promote the formation of accountable care organizations (ACOs). ACOs can be hospital or clinician group led and work to coordinate care for the defined population of Medicare beneficiaries they serve. ACOs emphasize value-based care over volume-driven care and reward or penalize clinicians based on their performance on cost and quality measures. The Medicare Shared Savings Program (MSSP) for ACOs was associated with modest cost savings while maintaining or improving patient quality of care. There are examples of home-based primary care-only-focused ACOs

that have been among the ACOs that have saved the most money for the Medicare program.

In addition, the recognition of the importance of assessing and addressing social determinants of health has accelerated home-based care in the context of other financially at-risk delivery models. Several home-based medical co- management commercial entities that contract with Medicare Advantage plans to provide co-management services in collaboration with patients’ primary care physician have emerged in the health care marketplace. These entities seek to improve patient engagement in care, address social determinants of health, improve care transitions, and care coordination, often with an underlying shared-savings model as the financial engine. Similarly, home-based palliative care has emerged as a specialized service utilized by Medicare Advantage plans and other financially at-risk health systems to address the needs of patients with palliative care needs and functional impairments with the goal of reducing hospital utilization.

Interdisciplinary team-based models of care providing medical care, nursing, and social work at home for older adults with multiple chronic illnesses, once seen only in academic medical centers, are being adopted more widely by health care delivery systems. These teams focus not on single-disease management, but on coordination of care, integration of patient goals and preferences, and improvement of patient outcomes relevant to this particularly frail and vulnerable group.

Over the past several decades, multiple home-based care models as described above have been developed and evaluated, often with clear advantages over traditional care approaches. The opportunity to start to align these models into a true and full continuum of home and communit-based care that also integrates social supports now exists. In the coming years, this continuum will be realized.

LTSS and home-based medical care are a varied collection of services and models aimed at allowing functionally impaired older adults to age in place and receive care in the home setting. Overall, these models are effective when appropriately targeted; older adults continue to prefer living in the community to living in institutions, and social pressures from an aging generation will only increase demand for such care in the future. The current fragmented system of LTSS will be untenable in the coming years as the

number of older adults with complex multimorbidity and functional disability increases. Emerging models of home-based medical care including home- based primary care, hospital at home, and others hold promise for improving health care for these patients, although systematic barriers exist to their widespread implementation. Creative economic, technological, and clinical solutions that focus on quality and cost-effectiveness will be critical in reforming the system to affirm and fulfill the public trust.

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Older adults regularly experience changes in health status that contribute to frequent transitions between different levels and settings of care. These movements within and across care settings are commonly referred to as “transitions of care,” and typically involve the management of a patient’s care passing from one team of providers to another. Transitions of care are widely recognized as a point of heightened vulnerability for lapses in patient safety, as patients are at risk of “falling through the cracks” due to inadequate care coordination, preparation, and support prior to, during, and after the transition period. Inadequate care coordination and management of transitions of care contribute to $25 to $45 billion in unnecessary care costs resulting from hospital readmissions and other avoidable complications.

Poor-quality transitions of care also contribute to substantial patient and caregiver stress and dissatisfaction. For these reasons, there is a sense of urgency in the United States to improve care management and coordination during transitions of care.

Older adults are at particularly high risk for experiencing adverse events during transitions of care. This is likely due to a number of factors, including their disproportionately higher rates of utilization of a range of different acute and postacute health services, increasing rates of multiple chronic conditions, and greater burden of conditions resulting in cognitive impairments, which may limit their ability to recognize or communicate important care needs.

This chapter provides an overview of transitions of care commonly experienced by older adults in the United States and discusses “transitional care,” which is defined as a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care in the same location.

Transitional care is increasingly recognized as fundamental to ensuring safe and effective management of both chronic and acute illness in older adults. It also necessitates the involvement of all members of the interdisciplinary team working together across care settings. This chapter will provide an understanding of effective approaches to improving the management of transitions of care for older adult populations.

Numerous factors pose barriers to the provision of high-quality transitional care, but one of the most important is health system fragmentation. The higher rates of acute and chronic illness in older adults predispose them to require care across multiple settings or fragments within the US health system, yet the health system fragmentation they experience is a newer phenomenon that has emerged and evolved over the past half-century.

Decades ago, most health care was provided within just a few settings by a small provider team that accompanied the patient across all settings.

However, following the implementation of US payment structures that incentivized services, settings, and practices that reduced acute care utilization and length of stay, there was substantial growth in subacute, postacute, hospice, and rehabilitative services. Concurrently, providers became more specialized, with clinical practice increasingly restricted to specific settings (eg, hospitalist, skilled nursing facility specialist, emergency medicine physician, etc). While this ideally enabled more cost- effective use of resources at different stages in care, the rapid growth of single-site physician specialists and new service settings represented a fundamental change in the nature of care delivery in the United States.

In the mid-twentieth century, physicians commonly followed their patients across settings of care and specialist services were more often delivered following close communication with a patient’s primary provider. It is now common for patients to travel between different settings of care and specialty providers without accompaniment of a consistent provider. For patients, this shift in care delivery has led to large gaps in care during the time after discharge from one setting and prior to being seen in the next, where it is unclear who is responsible for the patient’s care.

With a shift away from acute care delivery, patients discharge from hospital settings sooner and generally more ill, yet they are often not adequately prepared to follow increasingly complex posthospital care plans. Minimal and often inadequate communication between care teams across settings compound these gaps, leading to confusion and delays in necessary follow-up care. Additionally, systems have been slow to develop infrastructures capable of meeting patients’ needs in this new fragmented

care delivery model. However, the need for high-quality transitional care to support patients during these system gaps is increasingly recognized.

Adverse consequences associated with poor-quality transitions have been well documented and include a range of undesirable outcomes for patients as well as their caregivers. Communication failures during the posthospital period are common and may involve the omission of vital elements of a care plan, such as information regarding mobility restrictions, medications, or diet orders. This may lead to inappropriate, disjointed, and/or harmful care in the next setting. For example, approximately one-third of patients discharge with pending laboratory tests that are not communicated to the next setting of care, and at least 10% of these could have led to actionable changes in patient care plans. Medication errors and/or discrepancies, which may be the result of poor-quality medication reconciliation or insufficient patient/caregiver education or support, occur in 30% to 50% of patients in the posthospital period. When serious, they can lead to a number of adverse events, including avoidable rehospitalization, emergency department utilization, and death.

Rehospitalization within 30 days of discharge occurs in 20% to 25% of Medicare beneficiaries and is more likely among certain vulnerable populations, such as older adults with functional or cognitive impairments. Research suggests that nearly half of these rehospitalizations could be avoided if better care were provided during transition periods.

Policy makers in the United States have long recognized poor-quality transitions of care as a dangerous and costly health delivery problem. The 2001 Institute of Medicine (IOM) report, Crossing the Quality Chasm, described the US health delivery system as complicated, poorly organized, and decentralized, resulting in “layers of processes and handoffs that patients and families find bewildering.” The 2010 Patient Protection and Affordable Care Act includes multiple provisions aimed at improving transitions of care, including financial penalties for hospitals with higher than projected rehospitalization rates. The legislation also includes financial incentives for the development of care models that enhance coordination, such as the Medicare Shared Savings Program for accountable care organizations (ACOs). ACOs consist of a group of providers who are responsible for

providing care for a group of patients across settings. The law authorizes financial incentives for ACOs that successfully keep patients out of acute care while maintaining high-quality care. The legislation also permits payment for care transition services to providers operating as medical home practices, which aim to manage and coordinate care for patients with chronic conditions. Following these policy changes, health systems have shown increased interest in adopting programs, policies, and interventions that improve transitions of care and decrease health system fragmentation.

More recently, policy changes from the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 have sought to improve transitions by standardizing patient assessment data in postacute settings and better matching patients’ clinical needs with the right postacute care environment (Table 18-1), which may have implications for discharge planning. Historically, provision of rehabilitation services drove Centers for Medicare and Medicaid Services reimbursement of skilled nursing facilities (SNFs) and home health agencies (HHAs), but documentation of patients’ progress varied from setting to setting and focused on amount of service provided rather than the outcomes of those services on patients’ function.

Beginning in 2019, the Patient-Driven Payment Model (PDPM) for SNFs and Patient-Driven Grouping Model (PDGM) for HHAs adjust payment based on patients’ clinical needs and utilize a single, standardized system for assessment and documentation. This shift in data collection has stewarded new opportunities to create a clinically meaningful record of a patient’s longitudinal progress through the postacute setting.

TABLE 18-1 ¦ POSTACUTE CARE CONTINUUM OF SERVICES

Limite d clinician training in transitional care The subfield of transitional care continues to grow, yet it remains a relatively new concept that has not been emphasized in clinical training programs until recently. As a result, many clinicians are unprepared to manage transitions of care successfully or even to recognize the consequences of health system fragmentation. Additionally, clinical training often takes place primarily in acute care settings. Many clinicians may have little to no exposure to other settings of care such as postacute care or home-based services. Postacute care services vary substantially in available resources, level of physician contact, and acuity of patient populations. Table 18-1 provides an overview of the continuum of postacute care settings. A lack of exposure to these various settings may contribute to a limited understanding of the unique needs/resources outside of hospital settings, leading to communication failures between hospital-based and postacute providers and inappropriate care plans. As a result, patients may receive inadequate services in the postacute period, causing distress for the patient/caregiver and potentially avoidable rehospitalizations. In some

cases, rehospitalizations may arise from clinical deterioration, but in others, patients/families may lose confidence in the setting’s ability to provide care and choose to return to the hospital. Even when patients discharge to a more intensive level of care than necessary, they may face risks for rehospitalization. In addition to occupying beds better utilized by others, they may quickly discharge to a lower acuity setting, facing the attendant risks of yet another handoff.

Patie nt/care giver underprepared for transitions Limited or inadequate preparation of patients and caregivers regarding what to expect at the next setting of care is also a common problem. Patients and their caregivers are often unaware of what to expect following hospital discharge or transitions of care. They often are not empowered to take part in their plan of care sufficiently. Patients’ and caregivers’ sense of underpreparation may not necessarily be due to a lack of discharge information, but more so due to the complexity and amount of information communicated are overwhelming. These vast quantities of information would be challenging for anyone to encode and retain in the short time frame for discharge teaching that is typically provided. It is also common for patients and their caregivers not to recognize that they are unprepared to succeed in their next setting of care until they arrive and experience a care failure in that setting.

Poor-quality communication among provider teams High-quality communication between care teams at points of patient transition across settings is essential to patient safety, particularly at hospital discharge. More than half of all avoidable events following hospital discharge relate to poor communication among providers. Physicians have traditionally played the key role in communicating a patient’s care plan to the next setting provider at hospital discharge, typically in the format of a discharge summary. The discharge summary is the only form of communication at hospital discharge mandated by The Joint Commission (TJC) and must be completed within 30 days of discharge, according to TJC standards. In this new era of health system fragmentation, most experts believe that this 30-day time frame is much too long. While TJC has minimal standards for the content of discharge summaries, these are widely considered by experts to be insufficient. Despite the importance of discharge summaries in facilitating coordinated care, physicians receive little to no training in discharge summary creation, and there is no mandated standard format for these documents. Perhaps unsurprisingly, research examining the quality and content of discharge

summaries has found that they routinely omit the most important care plan components, such as code status, diet, warfarin instructions, and pending laboratory tests.

While a physician has historically been the recipient of hospital discharge summaries, patients now discharge to a range of postacute care facilities with varying multidisciplinary clinician teams who may require different information than what has been traditionally included within discharge summaries. Poor-quality discharge communication is particularly problematic for transitions to SNFs. SNF staff rely heavily on written discharge communication, which may serve as the only source informing a patient’s care plan for up to 30 days postdischarge. In focus groups, SNF nurses have reported regularly receiving discharge information that is untimely, incomplete, inaccurate, or conflicting. Because discharge summaries often dictate a patient’s plan of care for a significant period of time postdischarge and clarifying the confusing information in discharge summaries often takes several days, nurses in SNF settings have identified a list of discharge summary components that they require to safely transition patients to posthospitalization care (Table 18-2).

TABLE 18-2 ¦ HOSPITAL DISCHARGE INFORMATION THAT SKILLED NURSING FACILITY NURSES NEED TO DEVELOP AND IMPLEMENT A SAFE PLAN OF CARE

Special Considerations for Transitions of Care among Older Adults Older adults are heavy users of a range of health care services, including acute care stays, postacute care, subacute care, and home health care

services. Those with one or more chronic conditions see an average of eight different physicians annually. Figure 18-1 depicts the experience of an older adult receiving care in a series of fragmented systems, where the patient often serves as the only link between providers, and communication and integration between providers are commonly infrequent.

Older adults experience a variety of transitions of care. Hospital discharge is a particularly vulnerable care transition for older adults and results in an adverse event for approximately one in five adult medical patients within 3 weeks of discharge. Furthermore, nearly 20% of Medicare beneficiaries age 65 and older experience rehospitalization within 30 days of discharge, accounting for over $17 billion in health care spending annually.

Patients increasingly discharge to a range of settings following hospitalization, with approximately 25% of older adults being discharged to a different institution and 12% being discharged to their homes with home health care services. Table 18-3 includes examples of different types of transitions in the level of care or setting that older adults may experience.

Older adults who may be at increased risk for rehospitalization include those with difficulty with activities of daily living (ADLs), socioeconomic disadvantage, depression, substance abuse disorders, a history of previous hospitalization, difficulty with treatment adherence or medication compliance, or cognitive impairment.

TABLE 18-3 ¦ TYPES OF TRANSITIONS IN LEVEL OF CARE OR CARE SETTING COMMONLY EXPERIENCED BY OLDER

While patients do not always transition between institutional settings, transitions to community settings may still include a range of other care provider teams who may manage medical needs following hospitalization, including home health teams and primary care providers.

High levels of stress and dissatisfaction often characterize experiences of transitions for patients and families. In addition to poor communication

between hospital providers, postacute providers, and primary care physicians (PCPs), ineffective physician-patient communication likely contributes to patients’ underpreparation for managing their care following transitions, particularly after hospitalization. Various communication failures involving and surrounding patients during transitions also lead to the lack of appropriate follow-up care (eg, visit with PCP following hospitalization), which likely increases risk for rehospitalization. Failure to receive follow- up care and the resulting subsequent negative sequelae may incorrectly be attributed to the patient’s noncompliance rather than other factors, such as inadequate preparation or education prior to discharge, leading patients and their caregivers to feel frustrated and unsupported.

Little research has examined patients’ and caregivers’ preferences surrounding transitional care. Some qualitative research has found that patients and caregivers struggle with hospital discharges. Patients report feeling anxious and reluctant to ask clarifying questions about posthospital care needs when hospital discharge occurs quickly or with little notice, leading to patients discharging without a clear understanding of their posthospital care needs. Patients and caregivers also expressed insecurities about their ability to ask questions of the care team. Table 18-4 includes quotations provided by patients and caregivers in research studies that illustrate their experiences surrounding transitions of care.

TABLE 18-4 ¦ THE EXPERIENCE OF CARE TRANSITIONS FROM THE PERSPECTIVE OF PATIENTS AND THEIR CAREGIVERS

High-quality transitional care can combat system fragmentation to better support patients in bridging the gaps during transitions of care. One central component of effective transitional care is identifying and engaging caregivers for patients whenever possible. This is particularly important during hospitalization. Prior to experiencing a transition, such as hospital discharge, patients are often overwhelmed and acutely ill. Furthermore, navigating care needs following transitions often places patients in situations where they must rely on social supports and resources beyond themselves.

These social supports (eg, caregivers) are more likely to be effective if they are engaged in and prepared for the posthospital period along with patients. This is critical for patients with cognitive impairments, such as dementia or delirium, who may struggle to retain information about the transition period. Effective transitional care also merits the involvement of the entire interdisciplinary team.

While most transitional care programs have focused on transitions from hospital to community settings, the common elements of these programs are applicable to supporting patients across any range of transitions.

have the ability to tailor their care responses to an individual patient’s needs and fully integrate with both the sending and receiving setting and are likely the most effective. Some specific elements of effective and high-quality transitional care include, but are not limited to: (1) involvement of the patient/caregiver in care plan decisions prior to and during the transition to ensure that their goals are addressed and that the plan is feasible, (2) patient and caregiver empowerment and preparation for necessary care in the posttransition period that is reinforced through a series of contacts before, during, and after the transition, (3) timely, complete, and accurate communication with the next care team with mechanisms for the receiving team to ask questions and obtain clarifications, and (4) high-quality medication reconciliation. Examples of activities that fulfill the definition of high-quality transitional care are provided in Table 18-5 and are contrasted with typical, less-optimal care activities that may facilitate a discharge but do not necessarily support a high-quality, coordinated transition.

TABLE 18-5 ¦ HIGH-QUALITY TRANSITIONAL CARE AS COMPARED TO LESS-OPTIMAL TYPICAL CARE

Involving patients and their caregivers in decisions about care plans prior to transitions addresses several important barriers to effective transitions. First, it enables patients to gain an idea of what to expect at the next setting of care, which may ultimately help them prepare for their needs. Early involvement in decision making also provides patients with the opportunity to express their goals and values, which may impact placement decisions.

Providing patients and their caregivers with the necessary empowerment, preparation, and support to manage their needs in the next setting of care successfully is critical. In successful transitional care programs, this preparation generally includes the following components: (1) education and empowerment in medication management, ideally using either in-person assessments or patient-/caregiver-led medication reconciliation techniques,

(2) ensuring adequate follow-up care is in place and that the patient/caregiver is prepared to actively participate in that follow-up, (3) education of the patient/caregiver about signs of a worsening condition (often referred to as “red flags”) and empowerment to act upon those signs, and (4) ensuring that patient/caregiver understands who to contact with follow-up questions and how to make these contacts. These core areas should be reinforced in the early discharge period through a series of contacts over time to adhere to standard principles of adult learning.

High-Quality Communication Between Sending and Receiving Care Teams High-quality communication is central to achieving safe transitions. While ongoing, bidirectional communication between the sending and receiving health care team would be ideal, typically, most communication between care settings occurs in a written format at one point in time.

Written discharge communication, primarily the discharge summary, is the primary and often only form of communication that accompanies a patient following hospitalization. For patients discharged to nursing homes, the orders received concurrently with or contained in the discharge summary can dictate a patient’s care for up to 30 days, so high-quality written communication is especially a key for these patients. Yet, as noted earlier in this chapter, the quality of written communication tends to be poor.

Several strategies can improve the quality of written discharge communication. First, whenever possible, a provider who is familiar with

the patient should create, complete, and sign the discharge summary. In current practice, discharge summaries are sometimes iteratively modified by multiple rotating providers until the time of discharge. In such cases, the posthospital care setting may receive several versions of discharge summaries with conflicting information. It is important to recognize that many of these settings, such as SNFs, are not capable of implementing last-minute changes in orders and may face long delays in responding to medication changes or special equipment orders due to the lack of on-site pharmacies and central supply services. Consequently, last-minute changes in discharge orders should be minimized and, when they do occur, should be communicated to the admitting facility using another method (eg, via phone) prior to patient transport. Because many postacute care settings require information about care plan elements that are not immediately available to the physician, engaging the interdisciplinary team in creating certain components of the document or providing recommendations for the document in the electronic medical record (EMR) may be advantageous. Some examples of these care plan elements may include information about behavioral symptoms in patients with dementia such as agitation, that are critical for staff in the next setting of care to be aware of in order to arrange appropriate staffing and supportive care. A care system can use a standard format for discharge summary creation to reduce omission of key information. A list of recommended discharge summary components required by nurses in SNF settings can be found in Table 18-2.

While written discharge communication is the primary form of communication for physician providers, other members of the care team should also consider verbal handoffs with providers in the next setting of care. Nurses in SNFs have identified high-quality verbal handoff with hospital nurses to be very helpful in preparing for patient transitions. This contact also provides an opportunity for both the sending and receiving end of the transition to identify and resolve relevant questions that may not have been recognized until patient transfer.

Medication reconciliation is an essential component of transitional care programs in which the patient, members of the health care team, and other caregivers can collaborate to improve medication safety as the patient transitions between health care settings (eg, hospital admission or discharge)

or other care units. Medication reconciliation is the formal process recognized by TJC of creating the most accurate medication list by comparing, or reconciling, the patient’s current list of medications with the medications ordered by providers upon admission, transfer, and discharge. TJC recommends five steps in the medication reconciliation process (Table 18-6). This process is intended to identify and resolve any medication discrepancies or errors, such as omissions, additions, duplications, and frequency or dosing errors, with the goal of preventing adverse drug events (ADEs) and subsequent patient harm. Since medication discrepancies are a major contributor to ADEs, TJC has made medication reconciliation a National Patient Safety Goal and requires all of its accredited institutions to have a process implemented at their site for reconciling medications. Despite these efforts, however, medication reconciliation processes have been challenging to perform effectively and consistently as evidenced by a continuing high prevalence of medication discrepancies for patients transitioning between health care settings and levels of care.

TABLE 18-6 ¦ PRIMARY COMPONENTS OF A MEDICATION RECONCILIATION

The medication reconciliation process starts by obtaining the patient’s medication history. Often, a physician, pharmacist, or nurse will obtain the patient’s medication history by (1) interviewing the patient and their caregivers, (2) accessing the patient’s past medical records, and (3) contacting other providers involved in the patient’s care and the patient’s community pharmacy for recently dispensed medications (Table 18-7). When creating the patient’s list of current medications, it is important to identify all medications the patient is taking, including prescription drugs, over-the-

counter medications, herbal remedies, and supplements. The patient’s medication histories are then reconciled with medications to be ordered to ensure that the new medications and doses are appropriate for the patient. Changes to the patient’s medication regimen are documented in their medical chart, and a complete medication list is communicated to the patient, caregiver, and next provider/team. Reconciling medications applies to all health care settings, including ambulatory care, inpatient services, emergency and urgent care, long-term care, and home care.

TABLE 18-7 ¦ INFORMATION FOR THE PREADMISSION MEDICATION HISTORY

Transitional care interventions support patients as they move between different settings of care and generally emphasize medication management, empowerment/support with self-care management, and posthospital contact with a care provider. Many of these interventions recognize nurses as clinical leaders for supporting patients and their families as they navigate transitions (Figure 18-2). They engage nurses as well as other members of

the interdisciplinary team in developing care plans, performing medication reconciliation, and supporting medication adherence and self-care in the early discharge period. Most transitional care interventions focus on transitions from hospital to community settings; however, emerging care models continue to be developed to support patients during a range of unique transitions. Some examples of specific transitional care interventions are noted below.

Interventions to Improve Hospital-to-Community Transitional Care Quality Home visit–based transitional care interventions that have been tested in randomized controlled trials include Coleman’s Transitions of Care Intervention (CTI) and Naylor’s Transitional Care Model (TCM). These interventions reduce rehospitalizations by about one-third. Both programs utilize posthospital in-home visits with a nurse practitioner to educate high- risk patients about their medications, medical follow-up, signs of condition worsening, and provider’s contact information. While contact with patients in these programs only lasts for a few weeks, the effect on rehospitalization has been shown to last up to 180 days—likely due to improved self- management. Both of these interventions, however, are limited to patients

Transitional care interventions utilizing similar steps as CTI and TCM have recently emerged to target vulnerable patients, including those with cognitive impairment, and those who refuse home visits or live too far from discharging hospitals to receive home visits. One of these, the Coordinated- Transitional Care (C-TraC) program, developed within the US Department of Veterans Affairs, is a low-cost, telephone-based program. It uses a nurse case manager to coordinate the patient’s transition via a series of protocol- driven in-hospital visits, intensive posthospital phone calls, and integration with in-hospital and posthospital clinical teams. In preliminary testing, the C- TraC intervention reduced 30-day rehospitalizations by one-third among enrollees, leading to a substantial cost avoidance. However, more rigorous testing is needed to better understand its impact.

Project Re-Engineered Discharge (RED) is an intervention based within the acute care setting that involves enhanced in-hospital discharge processes and education. A randomized controlled trial of Project RED showed a decrease in 30-day emergency room visits but no significant effect on rehospitalizations. The average age of the population tested in the study was 50 years, much younger than the typical older adult population at most risk for rehospitalization. Given this and the limited posthospital support available within this program, its role in high-risk and older patient populations remains unclear.

The success of a care transition relies not only on adequate preparation of patients/caregivers and effective communication between health care teams but also on the selection of the most appropriate setting for subsequent care. Development of clinical decision support tools could assist in directing clinicians to the best postacute setting for patients’ needs. Such tools have shown promise in identifying patients in need of postacute care and, when used to develop the discharge plan, may reduce inpatient rehospitalizations. More investigation is necessary to determine whether these tools could be incorporated broadly into routine practice and whether the reductions in rehospitalization can be replicated.

Interventions to Improve Nursing Home–to–Hospital Transition Quality Nursing home patients experience a high degree of costly transfers to the hospital setting that may be avoidable through earlier recognition of changes

in condition by nursing home staff. These transfers are burdensome for nursing home residents, many of whom may be physically frail and have some degree of cognitive impairment. Interventions to Reduce Acute Care Transfers (INTERACT) is a program that was developed to reduce the frequency of transfers to acute care for nursing home patients by supporting nursing home staff’s ability to identify, assess, and communicate changes in condition. The program consists of a toolkit composed of: (1) a Situation- Background-Assessment-Recommendation (SBAR) tool to support effective communication between nurses and physicians, (2) an early warning tool designed to promote early recognition changes in condition, (3) a hospital transfer review tool to support review of hospitalizations and potentially avoidable causes, and (4) a standardized patient transfer form to communicate key patient information during transfer. INTERACT tools are available for no cost for clinical and educational use at www.interact- pathway.com and consist of a toolkit that supports both education for nursing home staff as well as implementation and data collection support. Data suggest that INTERACT tools can decrease rehospitalizations in engaged facilities that implement the interventions fully.

Several other resources and programs are also available. The Society for Post-Acute and Long-Term Care Medicine/American Medical Directors Association has several relevant tools on its website. A CMS demonstration program involving 7 sites and over 140 nursing homes demonstrated significant reductions in all-cause hospitalizations among long-stay nursing home residents. All of the interventions involved components of the INTERACT program and provided additional on-site personnel to help implement the interventions. Examples of additional interventions included a focus on advance care planning, medication reconciliation, oral health care, and telemedicine. One site that provided on-site nurse practitioners to implement core components of the INTERACT program showed a 30% reduction in all-cause hospitalizations.

Older adults with cognitive impairments, such as dementia, are at increased risk for experiencing negative outcomes associated with transitions.

an alarming 40%. While little research has examined reasons for this increased risk, it is apparent that the limited capacity to learn, recall, and effectively communicate elements of their care plan among those with dementia may result in an inability to compensate for poor communication across clinical teams and may play a role in subsequent rehospitalizations. Persons with dementia also have difficulty adapting to stressors and responding to change. They generally benefit from consistency in caregiver teams and environment, making transitions across care settings particularly burdensome. Considerable changes in surroundings (eg, transitioning from nursing home to the hospital) for a person with dementia may result in increased behavioral symptoms, such as agitation or increased depressive symptoms.

While most people with dementia spend most of their life in community settings, they also experience transitions into permanent care (eg, placement in a nursing home) more often than non-cognitively impaired older adults.

Transitions into permanent care represent considerable changes for both the individual with dementia and their family/caregivers. Persons with dementia have expressed a desire to be involved in the transition process and to have their family members engaged to offer support. However, research also suggests that persons with dementia may be excluded from the decision- making surrounding transitions of care. The lack of inclusion of people with dementia of care decisions may result from the incorrect assumption that people with dementia are unable to contribute to decision-making conversations or that these conversations will result in distress due to a lack of comprehension. Though some individuals with more advanced cognitive impairment may be unable to participate in their care at this level, many individuals with mild to moderate impairment could benefit from this opportunity, as providing input into the decision to transition into a nursing home for permanent care has been shown to lead to a greater sense of acceptance with the decision. Developing a longitudinal care plan may help incorporate the wishes and values of people with dementia into transitions of care more effectively. Early discussion about preferences regarding settings of care and whether the benefits of seeking acute care for an illness outweigh the harms of the transition to an unfamiliar environment can guide surrogates’ choices in later stages of dementia. Dementia-specific advance directives have been suggested as one means of conveying these wishes.

Transitions near the end of life are common in those with and without dementia. Such end-of-life transitions may not improve quality of life, instead adding to suffering and burden, and may be preventable. More than 80% of individuals experience at least one transition between health care settings in the past 6 months of life, with about one-third experiencing four or more transitions. Despite the substantial burden associated with transitions for persons with dementia, they experience more transitions within the past 3 months of life than those without dementia. Advance care planning may reduce the likelihood of burdensome transitions, particularly when completed earlier in the course of illness.

Patients with dementia also benefit from inclusion in transitional care interventions that emphasize empowerment and preparation of caregiver and adapt patient education strategies to meet the needs of individuals with cognitive impairment. The C-TraC program previously described is one example of a transitional care program that actively engages caregivers and uses methods of spaced retrieval to aid in information retention in persons with dementia.

Most community-dwelling older adults with dementia live with or receive frequent support from informal caregivers, who are often but not always family members. Because caregivers of people with dementia experience considerable burden and negative health outcomes related to the caregiving role, it behooves clinicians overseeing transitions of care for persons with dementia also to be responsive to the needs of their family/caregivers. Caregivers often experience guilt and frustration surrounding transitions into nursing home settings and are rarely prepared to manage these emotional conflicts and sense of bereavement during placement. Caregivers also generally express a desire to continue to participate in care following the transition. Enhanced support and counseling surrounding transitions to nursing home placement have been shown to have both short- and long-term benefits for caregivers. Providers may wish to refer caregivers to these or similar programs and may also refer caregivers to website resources provided at end of this chapter (Table 18-8). Table 18- 9 illustrates a case example of the experience of transitional care for an older adult with dementia that illustrates a life-threatening complication and hospital readmission because of poor communication between the hospital and the SNF.

TABLE 18-8 ¦ EDUCATIONAL RESOURCES FOR PATIENTS AND FAMILIES DURING TRANSITIONS OF CARE

TABLE 18-9 ¦ CASE EXAMPLE OF A POOR-QUALITY TRANSITION FROM HOSPITAL–TO–NURSING HOME FOR A PERSON WITH DEMENTIA

The authors would like to acknowledge Jacquelyn Mirr, Brian Mirr, and Michael Gehring for assistance with formatting/graphics.

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The purpose of this chapter is to provide an overview of value-based care as it currently exists in the United States, and to highlight aspects of common value-based care models that are most relevant to the care of older adults. In many respects, geriatricians and other geriatric health professionals are in a position to make these value-based care models successful and to assume leadership roles in them. Value-based care requires health professionals to work as interprofessional teams and participate in care coordination across settings of care, to understand evidence-based care and as well as its limitations in older adults, and to practice person-centered care in the context of evidence and many other factors important to patients—all skills that geriatricians and other geriatric health professionals have developed.

At the same time, older adults with multiple comorbidities and related health care needs are likely to benefit from being in one or more value-based care models when implemented effectively. These individuals are especially susceptible to the potential for excess diagnostic testing, therapeutic intervention, and related complications and costs that are common in the Medicare fee-for-service system. Value-based care mitigates the incentives that create this situation and can therefore result in better outcomes and lower costs for the vulnerable older population.

In most industries, value can be defined as the output achieved relative to the cost incurred. In health care, the most common definition of value is the patient health outcomes achieved per dollar spent. Central to the concept is that the value should be to the patient. Importantly, value is defined by both

the quality of outcomes and the costs incurred. Cost-containment efforts without a focus on improving value may negatively impact patient health outcomes. Efforts devoted to improving quality metrics alone may not be sustainable or may not meet the needs or preferences of patients.

In the Porter model of value-based care, the outcomes that a patient experiences can be considered the numerator, while the cost of providing those outcomes can be considered the denominator. To improve the value of care, a provider can try to address either factor. However, in practice, addressing both simultaneously is often necessary. Value-based care can be seen as a direct response to more traditional models of fee-for-service medicine. In fee-for-service, providers are simply paid a set amount for each unit of care they provide. Under fee-for-service, there is no incentive to improve on patient outcomes and there is a strong incentive to provide more care than is necessary. Engaging in value-based care should be an aspirational goal of many health systems as it puts the care of the patient first and the profit or provider second. A well-designed value-based care system will ideally maximize value for patients while at the same time providing value and potential cost savings for providers and payers as well.

Plans (ISNPs), the Merit-Based Incentive Payment System, and the Skilled Nursing Facility Value-Based Purchasing Program (SNF VBP).

3. There is no silver bullet in achieving value-based care. Rather, each initiative has strengths and drawbacks and forms a part of the greater whole.

In a simple model, we can consider care on two axes (Figure 19-1). On the x-axis we can consider a spectrum from the least expensive to the most expensive care. On the y-axis we can consider treatments that provide minimal benefits to patients to treatments that provide a large benefit for outcomes. If the upper left quadrant can be considered high-value care— delivering positive outcomes for low cost, then its inverse is in the lower right quadrant: low-value care. Low-value care is often defined as “services that provide little or no benefit to patients, have potential to cause harm, incur unnecessary cost to patients, or waste limited healthcare resources.” Prior work has found that as much as $300 billion is spent annually on services that can be considered low value. As health systems and providers try to embrace concepts of value-based care, finding ways to maximize the use of high-value care and minimize the use of low-value care are often both necessary.

While there are many initiatives underway that aim to reduce the use of low-value care in clinical practice, one initiative that has grown in prominence is Choosing Wisely. Originally a project of the American Board of Internal Medicine, over 90 medical societies now publish lists of services that are deemed to be low value that clinicians should seek to avoid. The American Geriatrics Society published a list of 10 treatments that should be avoided (Table 19-1). While some work has found that the introduction of these lists are an important first step in addressing low-value care, they are a single component of a larger constellation of interventions that can help move delivery closer to value-based care.

TABLE 19-1 ¦ AMERICAN GERIATRICS SOCIETY CHOOSING WISELY GUIDELINES

While models of value-based care are variable and there are no one-size- fits-all approaches, there are several features that tend to be included as a component of most models. First, they tend to feature some type of financial risk sharing between the payer (eg, a health plan) and the provider (eg, a hospital). Second, there is almost always effort devoted to quality measurement. Third, there is often increased care coordination than might be traditionally included in a fee-for-service model. Fourth, many models also embrace concepts of population health management.

Financial risk sharing can take many forms and exists along a spectrum (Figure 19-2). Risk can be understood as the possibility of losing or gaining money on an investment. In health care, there can be substantial heterogeneity in the patients’ experiences and care needs. When a provider assumes more risk, they are making themselves more responsible for that variation. In traditional fee-for-service health care, a provider does not bear any risk financially. A provider is paid a fixed amount for providing patient services, and is not liable to losing financially if the patient requires more care or does not achieve desired outcomes. In fee-for-service there is an incentive for providing excess care that may not be beneficial to patients or the US health care system as a whole. In value-based care, providers take on more risk, which incentivizes the provision of higher quality services.

When a provider takes on risk, it can take the form of upside risk or downside risk. Upside risk is the ability to benefit financially for delivering high value care and is also sometimes called one-sided risk. In the most basic iteration of upside risk, a provider may be “paid for performance”; receiving financial bonuses for delivering certain levels of quality. Another example of upside risk is in the early Medicare shared savings accountable

care organization (ACO) models. If providers were able to meet quality standards and provide care under a financial benchmark, they could “share” some of those savings with the Medicare program. The upside risk models provide the least uncertainty to providers as they are not liable to repay any financial loses, however the ability to benefit in these models are typically more limited.

In downside risk models, a provider who does not meet a financial benchmark for their patients may be liable to refund a payer for the losses they incur. Downside risk may provide a stronger financial incentive to deliver on high value care. An example of downside risk is payment penalties under the hospital value-based purchasing program. If a hospital does not meet specific quality benchmarks, the Medicare program may withhold payments by 2%. Models that include both upside and downside risk are called two-sided risk models.

The next level of risk is episode-based payments. Under episode-based payment models, a provider may be paid a lump sum to cover all services a patient may need related to a specific condition. The Medicare program has launched several episode-based payment models, such as the Comprehensive Care for Joint Replacement (CJR) model. In the CJR model, providers are paid a single amount to cover all the care a patient needs for a lower extremity joint replacement, for up to 90 days postdischarge. If, for instance, a patient is readmitted to the hospital unnecessarily, the provider stands to lose financially; however, if care is delivered in an efficient matter, then they may benefit financially.

The highest level of risk a provider may take on is full capitation. Under full capitation, a provider or health plan may be paid “per capita” or per person. These payments are typically “risk-adjusted,” paying a higher amount for patients who have more complex care needs. The most prominent example of full capitation in the US health care system is the Medicare Advantage (MA) program, where private plans are paid per capita for their enrollees. If a plan is successful in reducing unnecessary care and preventing adverse events such as hospitalizations, they may benefit substantially; however, if patients are repetitively hospitalized, the plan may lose substantially on that patient. While under full capitation, the payer or provider assumes the highest level of risk, they also stand the benefit the most if they provide high value care.

Quality measurement is vital in value-based care for two primary reasons. First, if value-based aims to deliver maximal outcomes for minimal costs, it is imperative to measure quality to ensure that patients experience beneficial outcomes. Second, in the presence of a risk-sharing model, without quality thresholds there would be an incentive for providers to “stint” on care or to save money by cutting back on services to the detriment of a patient. In a fully capitated model, without the assurance of a baseline level of quality, a provider could deny all services to a patient in order to retain all of the payment they received for that patient. We describe quality measurement in value-based care in greater detail later in this chapter.

Care coordination is defined by the Agency for Healthcare Research and Quality as the “deliberate organizing of patient-care activities and sharing information among all of the participants concerned with a patient’s care to achieve safer and more effective care.” While this definition focuses on clinical care processes, other definitions also include a focus on the coordination of social and community-based services that might be beneficial to patients with advanced care needs. Despite varying definitions, care coordination can be an important tool for achieving value-based care. Table 19-2 lists common care coordination activities. If the two primary inputs into value-based care are reduced costs and improved patient outcomes, care coordination has the potential to address both.

TABLE 19-2 ¦ EXAMPLES OF CARE COORDINATION ACTIVITIES

On the efficiency and cost side of the equation, care coordination can play an important role in organizing a patient’s care and preventing unnecessary additional visits and complications. After a hospitalization some patients, particularly those with advanced care needs, may have difficulties in making it to follow-up appointments. A provider who successfully coordinates a patient’s care, perhaps through the use of a patient navigator or community health worker, may be able to aid patients in receiving all of their necessary follow-up care, thus reducing the risks of an adverse event and a preventable hospital readmission. Other patients may see providers from different health systems and receive duplicative care across sites such as extra blood tests or imaging. These studies can result in false-positive or abnormal, but clinically insignificant findings that often result in repeat or follow-up testing. A system that is able to coordinate a patient’s care across

providers, potentially through the use of electronic health records, may be able to prevent unnecessary services and invasive procedures by communicating results between providers rather than duplicating them.

Care coordination approaches can also be used to potentially improve upon patient outcomes. Some patients may have challenges in understanding and successfully taking their medications. Inappropriate medications and poor adherence to necessary medications may have downstream negative health effects. Successful care coordination could include regular medication reviews and reconciliation by the patient’s care team to ensure that the patient has access and is taking the medication that they need. In other instances, a patient may benefit by being connected to social services in their communities such as meal services or transportation to their specialty visits, which may both lead to improved patient outcomes.

Population health can be defined as the health outcomes of groups of individuals including the distribution of such outcomes within the group. Population medicine acknowledges that many of the outcomes that patients face are driven in part by what occurs in the community. As such, population health management has become a key feature of value-based care. If providers are going to be held accountable for the outcomes their patients experience, there can be a strong incentive to promote positive outcomes through community-wide interventions and public health efforts. Examples of population health interventions for older adults include those targeted toward lifestyle behavior change, fall risk, polypharmacy, psychosocial interventions, and disease management programs. Common population health problems that lead to adverse health for older adults can include physical inactivity, unhealthy diets, and smoking. To address these concerns, patient- centered medical homes (PCMHs) often provide nutritionist services for patients and many MA plans cover smoking cessation services. To address concerns around fall risk, MA plans have recently started covering the costs of in-home safety modifications, such as the installation of handles in showers and hallways, exercise, and other fall prevention interventions. To address concerns of loneliness and depression among older adults, some hospitals and Program of All-Inclusive Care for the Elderly (PACE) programs have invested in friendly visitor services to ensure that older adults living in the community are able to socialize. Many ACOs and health plans

also provide patients with disease management tools, such as remote glucose monitors, in order to ensure that the needs of their patients are being met.

While each of these value-based models may need to cover the upfront costs of these services for their patients, over time, they may be beneficial in improving patient outcomes and reducing the risk of costly events such as hospitalizations.

Population health strategies can also be helpful to value-based practices to identify patients at highest risk for complications and health care costs. In heterogeneous populations of older adults, some will be relatively healthy and others will have multiple comorbidities requiring considerable medical care. We know that in such populations, a relatively small proportion of patients can account for the majority of costs. Various models, such as for hospitalizations, readmissions, injurious falls, and other expensive events, can assist in identifying those at highest risk and developing targeted and tailored interventions that can improve care and reduce morbidity and related costs.

In recent years there has been a dramatic shift toward embracing different models of value-based care in the US health care system. Many of these new models have been developed by the Centers for Medicare and Medicaid Services Innovation Center (CMS CMMI) and focus on addressing the needs of older adults. Below and in Table 19-3 we present an overview of several of these new value-based care models.

TABLE 19-3 ¦ MODELS OF CARE

Medicare Advantage (MA) or Medicare Part C is a privately run segment of the Medicare program. While in traditional Medicare, the federal government is the primary payer for patient services; in the MA program private insurance plans are paid by the government to cover the needs of their enrollees. MA is a fully capitated program—plans are paid a single risk-adjusted amount by CMS to cover all enrollee needs each year. While MA plans need to cover at least the same benefits available in traditional Medicare, they may also provide additional supplemental benefits such as fitness programs, meal delivery services, and dental coverage, which are not available in traditional Medicare. Plans also have flexibility in the premiums and other cost-sharing that they require, and can limit patients to specific

provider networks and require prior authorization for services. Enrollment in MA is rapidly growing and, as of 2019, included over 22 million enrollees representing 34% of all Medicare beneficiaries.

Institutional Special Needs Plans (I-SNPs) are MA Special Needs Plans that restrict enrollment to individuals who, for 90 days or longer, have had or are expected to need the level of services provided in an institutional environment (skilled nursing facility [SNF], long-term care nursing facility [NF], a SNF/NF, intermediate care facility for individuals with intellectual disabilities [ICF/IDD], or an inpatient psychiatric facility). There is strict enrollment marketing guidance from CMS, and the I-SNP does not have direct access to institutionalized long-term residents unless they express an interest to be contacted by the I-SNP sales team.

Institutional Equivalent Special Needs Plans (Ie-SNPs) care for individuals who are living in the community, but qualify for an institutional level of care (LOC). For an I-SNP to enroll MA eligible individuals living in the community, but requiring an institutional LOC, the following two conditions must be met:

Dara fr???? Da??JscllrMe.r U, A1?11 DC, Ke.it}1 RE, Ki?sl1 'R Alexandcr J'A, Lc?wiery }C. F?.steri??g i??1ple?11e,1 ft?tion of /?en.llh services 1-ese,ar:cl1 flri,iit16YSi?rto practic:c: a co11.s?li dated f1??r1e?11?rkfo1· a,iv(i?r:i??_g i??ipler??e11tatiQr1 Sf.i??jce. 1???p1 ,,1.e:?t •c:i. 2009;4:50.

As the health care delivery moves toward value-based care approaches, it is inevitable that challenges with these approaches will continue to arise. Two of the more pressing issues facing value-based care today are the burdens that measurement may have and how to best risk-adjust performance measures.

Burdens and challenges of measurement One potential concern that has arisen in value-based payment models is the number of different measurement schemes that a single provider may be subject to. A single hospital for instance may be subject to the value-based purchasing, may be organized as an ACO, and may participate in bundled payment programs. Each of these programs brings its own success metrics, spending targets, and quality measures. As such providers may need to spend considerable amounts of time devoted to meeting each of these different administrative requirements. One study of four common specialties estimates that physicians in the United States may spend more than $15 billion a year in quality reporting. Another study found that CMS itself may have spent $1.3 billion alone in the development of quality measures for value-based care models. Despite these burdens, value- based care may have the potential to substantially impact patient care positively; however, this challenge may call for a greater harmonization of success metrics across models of care. In addition, measures that are appropriate, and not counterproductive, for older adults with multiple comorbidities and those with life-limiting illness are essential to improving the quality of care for this population. For example, tightly controlling diabetes or hypertension in these patients is not evidence-based. Quality measures that do not consider the many patient-centered factors related to treatment decisions in vulnerable older patients could result in more harm than good in terms of driving episodes of hypoglycemia and their consequences, and hypotension and near syncope and falls.

Risk adjustme nt The issue of risk adjustment is central to the success of value- based care. Risk adjustment is a statistical process that considers the underlying health status and spending of enrollees when setting quality and spending benchmarks. In a value-based model that takes quality and spending into consideration, without risk adjustment there may be an incentive not to provide care for patients with more complex care needs. Under capitation for instance, a patient with advanced needs will almost definitely cost more

money to take care of than a healthy patient, so a health plan or a hospital would have a strong incentive to “cherry-pick” healthier patients who will save them money. Risk adjustment takes account of a patient’s underlying risk of adverse outcomes and high spending, and will lead to higher payments for their care than a healthier patient. One example of risk adjustment that the Medicare program uses is Hierarchical Condition Categories, which assign risk scores to patients on the basis of specific chronic conditions and are used to adjust payments in MA. A list of common HCC codes and the adjustment factor attributed to each is in Table 19-5.

TABLE 19-5 ¦ COMMON HIERARCHICAL CONDITION CATEGORY CONDITIONS

If perfectly implemented, risk adjustment will make it no more expensive to care for complex patients and ensure that the outcomes of complex patients are taken account of when evaluating quality. In practice however, risk

adjustment is unlikely to be perfect. There are several studies that find that despite the use of risk-adjustment methods across all CMS value-based payment models, in many cases the providers who treat more complex patients are still disproportionately penalized, meaning the risk adjustment did not adequately account for their higher care needs. Other studies have found benefits from incorporating social risk factors into risk adjustment as well. While traditional risk-adjustment approaches adjust for age, sex, and chronic conditions, there is growing evidence that these algorithms may benefit by also adjusting for factors such as socioeconomic status. An additional concern with current risk-adjustment efforts is the potential for upcoding, or administratively making a patient appear more ill in an effort to boost payments or performance on quality scores. As value-based care continues to evolve, risk adjustment will continue to be a key area of focus.

The shift from fee-for-service toward value-based care models is likely to continue for the next several years in the United States. Value-based care programs mitigate the financial incentives in the Medicare fee-for-service system to perform tests and procedures that may cause more harm than good in vulnerable older patients with multiple comorbidities, as well as those near the end of life. There are many current value-based payment models relevant to the care of older adults, including the MA program, ACOs, bundled payments, the PACE, and I-SNPs, among others. Robust and clinically valid quality measures are critical to the success of these programs, so that financial considerations do not result in less care than is appropriate and lower quality. While the specific names and structures of value-based models of care are likely to evolve over time, the underlying principles will provide substantial benefit for the older population.

Geriatricians and other geriatric health professionals have the training and experience to help make these programs successful and to assume leadership roles in them.

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Social workers provide services to older patients across a continuum of care needs that range from supporting community living to providing palliative care services at the end of life. This occurs in many different health care arenas including institutional settings, such as acute care hospitals, nursing homes, and other long-term institutional settings, as well as in patients’ homes in the community. Given the multiple settings that social workers function within, the way that they refer to those they work with can vary. In more formal and medical settings (eg, hospitals) the term “patient” is most frequently used. In long-term settings (eg, nursing homes and assisted-living facilities), the term “resident” is often used. In community settings, the terms “client” or “consumer” are favored as they emphasize agency and autonomy. Social workers support and enhance the adaptive capacities of patients within their living environments and are knowledgeable about interviewing, assessment, and intervention in social problems faced by individuals, couples, families, and groups. Using negotiating skills, social workers also mediate conflicts and obtain resources for clients and their families.

Knowledge of group process makes social workers effective in forming natural helping networks and serving as members of interdisciplinary teams. Their expertise in coordinating services within a single organization or across different agencies or settings helps to ensure appropriate and adequate care for older patients. Social workers often work on interdisciplinary teams in health care settings benefiting physicians, nurses, and other health care workers as well as the patients they serve.

While 76% of social workers in health care settings work with older patients, not all social workers have specialized training in geriatrics. Proper

care provided by gerontologically trained professionals including social workers can reduce the cost of care by 10% each year in hospitals, nursing homes, and patients’ homes as well as improve psychosocial outcomes and reduce mortality.

This chapter describes the key roles for geriatric social workers, the practice issues they face, and the settings in which they work.

Key Clinical Points

There are unique practice issues and considerations in older populations that face particular vulnerability because of oppression and/or poverty due to race, ethnicity, immigration status, sexual orientation, gender identity, or HIV/AIDS diagnosis.
Several core issues emerge when working with people who face abuse, neglect, mental health concerns, cognitive impairment, and substance or alcohol misuse.

The roles social workers play vary within health care settings (Tables 20-1 and 20-2). Social workers provide direct service to older adults and facilitate linkages between service workers and agencies.

TABLE 20-1 ¦ THE ROLES SOCIAL WORKERS PERFORM

Social workers meet face to face with patients and consumer groups to provide services as caseworkers, therapists, group workers, or educators. Individual casework and counseling services help older adults who have mental health problems or need help with resolving issues in areas such as housing, finances, or interpersonal problems. Therapy includes meeting with individual older adults, with partners, as well as with groups of older adults who are experiencing concerns related to their families. Such therapies could involve helping grandparents with resources and tools for raising grandchildren, aiding families in coping with an aging parent with dementia, or supporting older couples as they struggle with debilitating health problems that can create emotional and financial strain on the relationship. Group work services include support groups for older adults with a variety of health concerns, such as cancer, low vision, or early-stage dementia. Support

groups have been particularly helpful to caregivers of patients with such diseases as Alzheimer, diabetes, and Parkinson. These groups, run by social workers, help caregivers better understand the disease process and provide information that helps them cope with problems of caregiving more effectively and thus improve the disease outcome. Groups can also focus on self-help issues, where older adults learn to deal with such problems as alcoholism, obesity, or smoking. Psychotherapy groups work to resolve such concerns as abuse (as victim or perpetrator), depression, and marital problems. Social workers also work directly with older adults and their families as educators and disseminators of information. For example, social workers provide educational sessions on caregiving, stress management, and various aspects of mental and physical health care.

Social workers link older adults to the services they need. This may be necessary because agencies fail to meet older persons’ needs, because older adults lack knowledge of available resources or ability to access those resources, or because older adults and their families need help in overcoming fears and concerns about using services. For example, family members struggling to provide home care to a mother with Alzheimer disease may be reluctant to participate in a support or educational group used by other family members in similar circumstances due to fear of revealing personal problems they and their mother face. Social workers can help overcome these fears by assisting family members in realizing that families coping with dementia face similar problems and have similar reactions to their circumstances. Social workers also work as case managers to help older adults receive services in a timely fashion. In general, case management involves screening, assessment, care planning, implementation, monitoring, and reassessment to evaluate ongoing service needs. Case management meets a variety of goals in numerous settings. The social worker assesses problems and needs to determine eligibility for services and financial resources. The social worker also links older adults to needed services. Family and friends may provide collateral information to help the social worker determine their capacity for support. Goals for a care plan are determined by discussing older adults’ perceptions of their needs. Social workers then identify interventions and resources designed to meet these goals. Subsequently, the social worker monitors the delivery of the services.

When an older adult requires care over a longer period of time, a social worker will reevaluate needs and necessary interventions and resources. Ultimately, a social worker will conduct an outcome evaluation to determine if the patient’s goals were achieved.

Social workers also work as mediators and advocate for their clients/patients. As mediators, social workers determine the issues behind a conflict. Social workers facilitate family discussion of issues identified by the family and older adults as important. For example, adult guardianship mediation can inform how the family can best help older adults preserve autonomy (or to maximize one’s greatest level of independent functioning).

Medical social workers serve important roles across the care continuum, from in-home services to acute care. Medical social workers perform roles such as patient advocate and counselors, providing psychosocial assessments, referring patients and families to medical resources, and providing patient and family assistance in obtaining financial and legal help. They provide education and support to link clients to resources. Table 20-2 lists a broader range of practice settings. Several of the central practice arenas are reviewed below.

TABLE 20-2 ¦ SETTINGS WHERE SOCIALWORKERS WORK AND ROLES THEY PERFORM

Home care is a term that encompasses a variety of services, including home health agencies, homemakers, home health aides and assistance, medical equipment and supplies, visiting nurses, caregiver respite, and other medical services provided in the home. One agency may provide one or several of these services to older adults. Social workers in home care address a wide range of issues including adaptation to illnesses and chronic conditions, decisions regarding end of life, dementia and behavior management, caregiving, issues of abuse and neglect, prescription drug misuse, and family discord. In addition, they provide financial management, address unsafe living conditions, connect to resources to provide safe living quarters, address social support, mental health, and legal issues, and support compliance with medical treatments.

Social workers work in direct practice and leadership roles in community health and mental health agencies. They work in nonprofit settings (eg, Alzheimer Association) as well as state and federal agencies (eg, Administration on Aging, Centers for Medicare and Medicaid Services).

Aside from issues related to psychosocial support and education, social workers can also develop policy and practice standards. Social workers who work in community mental health agencies are part of a team of mental health practitioners, which includes nurses, psychologists, and psychiatrists. Social workers conduct client assessments, run support groups, provide emergency and crisis services to older mental health clients and their families, and refer these people to other resources in the community such as adult day care, respite services, and partial day treatment programs. They often provide therapeutic interventions in the form of brief psychotherapy and behavior modification to individuals or groups and provide indirect services through community education and consultations in long-term care facilities.

Social workers assist with supportive housing, daily living skills, transitional employment, and counseling needs.

Social workers in nursing homes and assisted-living facilities have diverse responsibilities to residents and their families, facility staff, and the overall institutional environment. Their assistance begins when residents move into the facility. Adjustment to a new living environment is faced by not only the older person, but their family as well. The social worker provides direct services to residents and their families as part of an interdisciplinary team. They assess the psychosocial needs of the resident and aid in the development of a care plan, guided by federal requirements of maintaining a minimum data set (MDS). The MDS is part of the US federally mandated process for clinical assessment of all residents in Medicare or Medicaid- certified nursing homes. This process provides a comprehensive assessment of each resident’s functional capability that helps nursing home staff (physicians, social workers, and nurses) identify health problems and develop strategies to address them. Social workers also facilitate psychosocial well-being among residents and their families, linking the resident and family members to services inside and outside the facility, helping with discharge planning, and serving as advocates for appropriate care and treatment for all patients and their families. Because social workers are often the only staff members focused on the psychosocial needs of residents and their families, they are well positioned to identify and address mental health issues. Often, they complete the cognitive, mood, behavioral, and psychosocial portion of the MDS along with the resident assessment

protocol, which can identify the mental health needs of residents. Assisted- living facilities are not required to have a social worker on staff and the roles of social workers in these facilities are less uniform when compared to skilled nursing facilities.

Social workers practice in all areas of hospitals, from the emergency departments to intensive care units. Social work practice with older adults in health care settings is focused on adaptation and coping with chronic illness, crisis management, adjustment to disability and physical limitation, decisions about end-of-life care, compliance with medical regimens, wellness, long- term care, quality of life, and discharge planning. Social workers also provide mental health services that address depression, substance abuse, management of long-term mental health issues, cognitive deficits, suicide prevention, and adjustment to changes in life by patients and families.

Medical social workers take on many roles such as patient advocate and counselor and perform psychological assessments, refer patients and families to medical resources, and provide patient and family assistance in obtaining financial and legal assistance.

In hospital settings, social workers are members of an interdisciplinary team, providing services to patients and families regarding assessments of a patient’s cognitive, emotional, and behavioral status, and connection to social support networks. Social workers counsel patients and families, assisting them in adjustment to illness and providing crisis intervention and connection to community resources. Additionally, social workers identify

interpersonal aspects of patients’ lives that contribute to positive outcomes in relation to their illnesses. They also address obstacles to medical compliance and financial concerns. Social workers advocate and affirm the cultural, linguistic, sexual, ethnic, religious, and other aspects of diversity present in their patients’ lives and advocate on behalf of patients with the health care team when patients face barriers to receiving care. For example, social workers can aid in the care of abused and neglected older adults by documenting and reporting instances of abuse and neglect and testifying in court with regard to these matters.

In acute care settings, where patient stays are very short, social workers focus on high-risk screening, brief counseling, bereavement services, discharge planning, collaboration, information, referral, follow-up, and

emergency services on-call programs. Social workers are typically assigned to specific medical or psychiatric departments in hospitals where patients are screened to determine whether they need social work services. Need for services is also conveyed to other health care professionals by having social workers attend team meetings and discharge planning conferences, by referrals from nurses or physicians, or by requests from patients and families. A social worker’s presence, when a diagnosis, death, or other unpleasant news is communicated, can ease shock and help individuals address the emotional loss and face forthcoming decisions. Additionally, the social worker can provide information regarding aspects of diseases, care options, and assistance in meeting patient and family needs.

Discharge planning is particularly important for older adults who are transitioning from the hospital to other facilities or their homes. Addressing older adults’ needs during discharge is necessary in order to allow the older adult the best possible scenario for recovery from illness. Social workers assess caregiving needs, the availability of social supports, family support, financial barriers, and home and community environment in facilitating the discharge.

Hospice social workers practice in a variety of end-of-life care settings, such as hospitals, nursing homes, assisted-living facilities, outpatient practices, residential hospice facilities, and in residential homes. Please review Table 20-3 for an overview of these settings. Palliative care requires an interdisciplinary team, where the social worker is a crucial member providing psychosocial support and referral to resources, easing transitions between settings, and addressing issues of loss for patients and families.

TABLE 20-3 ¦ SOCIAL WORKERS IN HOSPICE SETTINGS

Social workers help those who are approaching death. Their work begins when patients enter into hospice or palliative care and continues with families and loved ones after death. Social workers provide a variety of services to address the needs of patients, families, and caregivers serving in a variety of roles such as liaison, educator, mediator, advocate, broker, and counselor. As patients face debilitating illness in palliative care, social workers help with the transition between care facilities, assessing readiness for palliative care and beginning to address the emotional and psychological aspects of nearing death. Social workers are pivotal in assessing and supporting patients, families, and caregivers in their psychological, spiritual, social, financial, and cultural needs at the end of life. Addressing loss is essential, as individuals and families may have difficulty communicating and accepting their feelings regarding the losses they face. Identifying social support for patients and families is important, as discord can arise when families come together at the end of life, and social workers can assist families to communicate and understand decisions, emotions expressed, and relationships.

Social workers act as brokers for resources and services to address the needs of patients who are dying and their families. They arrange services, facilitate communication among family members, provide services to fulfill last wishes, and provide assistance with funeral plan arrangements. As an advocate, the social worker supports and represents patients’ and families’ needs, wishes, and desires to the health care team and recognizes the dying person as a social person during the end-of-life stages. As a counselor, the social worker addresses the psychological, emotional, and spiritual needs of the family in addressing losses and illness and reconciling relationships.

through individual counseling sessions with family members, support groups, grief camps for children, and formal ceremonies and services for families who have lost loved ones. Social workers help patients and families understand their options, identify services they need, and fill out the necessary paperwork to secure these services. They also help them fill out other important forms like advance directives.

Geriatric social workers strive to meet the basic human needs of all older adults, with a particular emphasis on those who are vulnerable due to discrimination, oppression and poverty. With health care provided in a myriad of public and private settings, the social worker acts as a broker, a mediator, and an advocate for clients.

This section reviews key populations served by social workers and some of the practice issues that come into play with older adults in these groups.

Social workers identify barriers to seeking help, such as stigma, denial, and financial and access barriers resulting from service fragmentation and gaps in health care. For some older racial, ethnic, and cultural minorities, health problems are rooted in historic experiences of discrimination that prevent access to the social service system. Therefore, culturally specific interventions should consider the unique background, context, and resources of the individual.

Social workers are uniquely situated to respond to the needs of older adults across racial and ethnic groups because of their skills in training and cultural awareness in service delivery. Attention to cultural diversity includes sensitivity to differences in cultural history, language, values, religion, ethnicity, nationality, and regionality, as well as recognition of within-group variation. For example, social workers use cultural assessment strategies to understand clients’ definition of a problem. During the assessment process, social workers working with culturally diverse groups evaluate attitudes toward health care and the clients’ belief about the causes of illness and benefits of health care services. As social workers attempt to understand clients’ problems, they evaluate the language skills, educational level, and degree of acculturation of the older person. In addition, determining the surrogate decision maker who has the authority to make care decisions is

important for the health care team to know. For females, in some cultures, a male decides how care proceeds. In some Native American cultures, generational standing predominates in care decision making. The patient’s use of language to label and categorize a problem, the availability and use of indigenous community resources, the decision making involved in problem intervention strategies, and the patient’s cultural criteria for determining problem resolution are important issues for the social worker and other health care workers to consider in working effectively with older adults and their families.

While there are common themes that are relevant to people of color and other minority groups, each group has its own cultural history relevant to care. This cultural history often contributes to health disparities that social workers must address. For example, racial and ethnic minorities have poorer access to care than the White population, and research suggests that this gap is not narrowing. Despite these collective findings, it is important to remember that racial, ethnic, and cultural groups are not homogenous.

Individuals and families have their own themes, caregiving patterns, and stories of access to and discrimination in social service and health care delivery.

While government programs such as Social Security, Medicare, unemployment insurance, and welfare have reduced the extent of poverty in the older population, poverty remains a significant problem. This results, in part, from the cumulative effects of lifelong discrimination, particularly for older adults of color, LGBT older adults, adults older than the age of 75, older adults residing in rural areas, and women. Underutilization of health and mental health services by older adults in poverty makes these groups a target for social work intervention. One significant barrier to meeting the needs of older adults in poverty is lack of knowledge about their problems and needs. Another barrier is that some older adults in poverty may lack resources, such as transportation, to access to care. Social workers aim to understand and eradicate these barriers that impede the development and delivery of appropriate services and connect older adults to formal and informal resources to aid impoverished older adults in rural communities, women, LGBT older adults, and racial/ethnic minorities.

Since the early twentieth century, rising numbers of older adults have arrived to the United States from Mexico, Cuba, and various countries in South America and Asia. As of 2018, one out of seven US residents is foreign born representing 14% of the population. Half of older immigrants have limited English proficiency with more than 40% of these older adults speaking Spanish. Older immigrants are also more likely to have lower incomes than nonimmigrants.

Older immigrants are more likely to live in households with extended family, children, and nonbiological family than are nonimmigrants. Families are often central to caregiving for aging relatives. However, demand for family caregiving often occurs in the context of limited coping resources, limited knowledge of services, misperceptions of eligibility requirements of government programs, and beliefs that children must provide caregiving.

Unfortunately, multiple roles may result in greater caregiving strain and increased neglect and abuse of older family members.

Older immigrants also encounter cultural and linguistic barriers to service use. Immigrants who migrated after age 60 face additional challenges, including little or no US work experience, limited ties to social institutions, and potentially limited English proficiency. Older immigrants comprise a diverse population, reflected in race and ethnicity, as well as age, length of residence in the United States, English language proficiency, and reasons for immigration.

LGBT older adults often comprise an invisible population that has special needs and face social service barriers based on individual and collective experiences of discrimination. Many LGBT older adults came of age at a time when failure to conform to gender or sexual norms resulted in job termination, involuntary hospitalization, cessation of parental rights, and criminal punishment. A fear of discrimination by health providers prompts many older LGBT adults who were once open about their sexual orientation and/or gender identity to return to the “closet” when entering long-term care facilities; and, some LGBT older adults fail to disclose their sexual orientation and gender identity to health care providers who have treated them throughout their life. Fear of differential or discriminatory treatment also precludes LGBT older adults from seeking health care and social

services at all, unless absolutely necessary. Discrimination and delays in accessing care lead to higher rates of disability, mental distress, excessive drinking, and poorer physical health outcomes for LGBT older adults.

Intersections of various identities (eg, race, ethnicity, sexual orientation, and gender identity) can create even higher health risks for particular communities. For example, one study found that African-American LGBT older adults had higher lifetime LGBT-related discrimination compared to Whites, which was linked to a decrease in their physical and psychological health-related quality of life (ie, vitality, mobility, pain, dependence on medical treatment, satisfaction with sleep, daily living activities, and work capacity). Transgender older adults have a higher risk of poor physical health, disability, depressive symptoms, and stress than cisgender (non- transgender) peers.

While the legal landscape for LGBT older adults is rapidly changing, ambiguity in state and federal laws often limits access to services and rights for LGBT older adults. LGBT older adults continue to experience discrimination from health care providers, and recent court battles about whether the Affordable Care Act protects LGBT people from discrimination have not helped. After courts affirmed marriage equality for same-sex couples, some health care providers began refusing care to LGBT older adults based on religious and moral reasons. Transgender older adults have reported particularly high rates of discrimination in health care. Many transgender older adults seeking medical services to affirm their gender identity also encounter obstacles in insurance coverage, which means many medical services are financially inaccessible.

Despite social, health care, and legal barriers for service delivery, many LGBT older adults have extensive support networks through partners and friends of similar age and rely on them for informal caregiving. Social workers can directly provide or connect LGBT clients to inclusive services and service providers and provide LGBT-friendly resources, such as physicians, living facilities, and attorneys to assist with health care documents.

Older adults can encounter HIV/AIDS either as patients with the disease or as caretakers for loved ones with HIV/AIDS. More than 50% of all Americans living with HIV are age 50 or older, facing the same risk factors

as younger people. Many newly diagnosed older people are “late testers,” meaning that they likely had HIV for years before their diagnosis and may face more immediate challenges than someone who is diagnosed early.

LGBT older adults and transgender people of color have particularly high rates of HIV/AIDS. Although older adults visit doctors more often than younger people, they are less likely to discuss sexual behavior with their physicians. Social workers can help to identify older HIV/AIDS patients and improve access to services and informal care that is necessary for successful treatment. Social workers offer educational information and coordinate services such as caregiver respite services, home health care and hospice care, individual and group supportive counseling, and financial assistance.

The abuse or neglect of older adults often surfaces in a health care setting. Many types of maltreatment, such as physical abuse, sexual abuse, and neglect (including self-neglect), result in injury, pain, and physical and psychological harm. Please review Table 20-4 for an overview. Other types of abuse such as financial and identity theft are more difficult to detect in health care settings. The assessment of mistreatment, which may require several contacts, involves an interview with the older adult to better understand risk. Cognitively impaired older adults who present with concerning complaints or who express concern for abuse and neglect should be taken especially seriously. While all states have mandatory or voluntary reporting laws, the older adult’s willingness to receive help, provided they have capacity, is voluntary. When a report of elder abuse is made to local authorities, additional personnel may be involved in safety planning. Social workers can be instrumental in helping older adults recognize the power imbalance in abusive relationships and devise strategies for protection. One of the biggest challenges that health professionals face consists of identifying and helping abused or neglected older adults who do not realize that they are victims of mistreatment. All forms of elder abuse can also occur when an older adult is residing in an institutional setting. Further details regarding elder abuse and neglect can be found in Chapter 48.

TABLE 20-4 ¦ ELDER ABUSE AND NEGLECT

Social workers are involved with assessing older adults with dementia and their caregivers. These assessments consider the client’s social and medical history, including a physical and mental status examination, an evaluation of the individual’s living environment, functional ability including both instrumental activities of daily living (IADLs) and activities of daily living (ADLs), social service needs and family dynamics, service and resource needs, and legal issues such as power of attorney and health care proxy, advance care planning, and end-of-life planning. Social workers also play a variety of roles on the interdisciplinary team used when an older adult and his/her family experience dementia. In the early stages of dementia, social workers can support the older adult with dementia and provide cognitively stimulating programs. In some cases, the older adult is able to plan for his/her own future physical and financial needs, which the social worker can facilitate. Social workers also help family members struggling with the physical and emotional changes in their loved one with dementia as it progresses. Social workers assist family members in navigating multiple caregiving responsibilities through therapy, resources, and support groups and can function as case managers for individuals experiencing cognitive impairment.

The Centers for Disease Control and Prevention (CDC) reports estimate that nearly 20% of people 55 years or older experience a mental health problem. The most common forms of mental health conditions include anxiety and depression. Table 20-5 provides an overview of common conditions. Older White men have the highest suicide rate of any age group. Individuals with

severe and persistent mental health conditions (a longstanding diagnosis that is disabling) require specialized attention, especially if their mental health condition interferes with their ability to function independently. Care planning for these individuals typically involves an interdisciplinary team that includes a social worker. Stigma toward mental illness leaves many older adults suffering in silence and too fearful or ashamed to seek help.

Language barriers and the lack of racial, ethnic, or culturally appropriate services also hinder older adults from seeking assistance. Social workers collaborate with a health care team to assess mental health issues and identify appropriate treatment and services. They can provide structured cognitive-behavioral, interpersonal, and problem-solving treatments that are effective mental health approaches, often in conjunction with prescribed medication. Pharmacologic interventions and psychosocial treatments are effective for older adults.

TABLE 20-5 ¦ COMMON MENTAL HEALTH CONDITIONS AND DEVELOPMENTAL DISABILITIES IN OLDER ADULTS

Substance and alcohol misuse often remain unrecognized by health care professionals who sometimes mistake symptoms for other age-related problems such as depression and dementia. Risk factors for substance and alcohol misuse include social isolation, living alone, chronic pain, and a variety of losses such as retirement, widowhood, and impaired mobility. Research suggests that a growing number of older adults misuse alcohol and other substances, including prescription medication and at a higher rate than previous generations. The National Survey on Drug Use and Health found that among individuals age 50 and older, over 12% were heavy drinkers, over 3% were binge drinkers, and nearly 2% used illicit drugs. Men older than age 65 had even higher rates of binge drinking at 14%. While misuse of individual substances or alcohol remains an important concern, another

growing trend among older adults consists of mixing alcohol with psychoactive medications, which can have dangerous impacts for many older adults. Because older adults frequently suffer from chronic pain, and serious adverse effects of nonsteroidal anti-inflammatory drugs are common, older adults frequently use opioids on a chronic basis. There is a fine balance between appropriate use and transitioning into opioid use disorder.

Moreover, a substantial number of older adults simultaneously use opioids and benzodiazepines, increasing the risk of serious adverse events such as falls and car crashes. Social workers aid other health care professionals in assessing substance and alcohol misuse and providing the necessary treatment. Social workers also provide successful educational interventions with older adults who are unaware that they are consuming too much alcohol or misusing medications.

Social workers with training and experience in geriatrics and gerontology are integral members of the health care team serving older patients. Their wide range of skills, as well as their knowledge of available services in a variety of settings, makes social workers highly valuable members of the inter-professional team serving older patients by identifying, evaluating, prioritizing and providing or arranging for the support services they need.

With ongoing efforts to further cost containment and effectively deal with treatment, models of health care delivery will continue to evolve (see Chapters 19 and 14). Innovations such as the patient-centered medical home, accountable care organizations (ACOs), and other forms of value-based care population health management, which combine new payment arrangements that reward for health outcomes achieved rather than paying a fee for each service rendered will further highlight the critical role of social workers in the care of older adults. Social workers are integral to these service delivery models. In team-based care, social workers play an important role in recognizing and addressing social determinants of health that drive both health care needs and costs. As health care delivery models evolve, social workers will continue to play a critical role in assisting older patients, their families, and other caregivers in navigating the complexities involved in receiving care.

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One often talks about wanting to hear the perspectives of everyday people, to inform gaps in knowledge that cannot be addressed through traditional research methods. The University of Michigan National Poll on Healthy Aging (NPHA) grew out of a desire to identify and fill some of those gaps through learning about issues that affect the day-to-day lives and experiences of older adults in the United States to improve their health and health care.

Launched in 2017, the NPHA examines older adults’ knowledge and attitudes on timely topics related to healthy aging through a recurring nationally representative household survey. Surveys are fielded two to three times per year with a sample of approximately 2000 individuals aged 50 to 80, and completion rates are typically 60% to 80% (Table 21-1). The NPHA is directed by the University of Michigan Institute for Healthcare Policy & Innovation and sponsored by AARP and Michigan Medicine, the University of Michigan’s academic medical center.

TABLE 21-1 ¦ NATIONAL POLL ON HEALTHY AGING, RESPONDENT DEMOGRAPHICS (N = 2023)A

As of June 2021, the NPHA has released nearly 40 reports on a wide range of topics related to healthy aging, including the impact of the COVID- 19 pandemic on the health and well-being of older adults. While these reports reach diverse audiences including the public, policymakers, and advocates, they offer unique insights into the perspectives and experiences of older adults that can be particularly helpful for geriatricians and other clinicians caring for patients in this age range. In this chapter, key findings and messages for clinicians are highlighted from a selection of past NPHA reports that can be organized into three broad categories: (1) health and health care (2) health care-related access and decision making, and (3) social aspects of health and well-being.

As the number of older adults in the United States increases, so does interest in strategies to promote “brain health” and ways to reduce the risk or slow the progression of dementia. In October 2018, the NPHA asked adults aged 50 to 64 about their memory, their concerns about developing dementia, and whether they would participate in dementia research.

Being worried about developing dementia was more pronounced among adults aged 50 to 64 with a family history of dementia compared to those without (66% vs 28%). Likewise, the 18% who had been a caregiver of a person with dementia were more likely to worry about developing dementia than those who had not been caregivers (65% vs 39%).

More than half of respondents (55%) reported doing crossword puzzles or other brain games, and 48% reported taking some type of vitamin or supplement to help their memory. About one in three (32%) said they took fish oil or omega-3 supplements. Overall, 73% of adults aged 50 to 64 reported engaging in at least one of these strategies to help maintain or improve their memory. About half of adults aged 50 to 64 reported being open to participating in research related to dementia, and those with a family history of dementia were more likely to participate in research.

Despite widespread concerns about developing dementia and engagement in strategies aimed at preventing it, just 5% of all adults aged 50 to 64, and 10% among those with a family history of dementia, reported having ever discussed dementia prevention with their physician. Such conversations could be vital opportunities for older adults to have their concerns addressed by using more evidence-based approaches to preventing or delaying cognitive decline. For example, there is such evidence for regular physical activity, controlling diabetes, quitting smoking, managing hypertension, and addressing hearing loss. In contrast, no major research studies support the effectiveness of supplements to enhance memory. The poll findings suggest that many adults aged 50 to 64 could benefit from discussing these strategies with their doctors to address their concerns about future memory loss.

Older adults often have complex medication regimens involving multiple prescription and nonprescription medications. An NPHA poll from April 2017 found that 69% of older adults had seen two or more doctors in the past year and 21% of older adults had used more than one pharmacy over the past 2 years. Both findings suggest that their doctors and pharmacists may not be aware of all the medications the person is taking. In addition, 27% of adults aged 50 to 80 reported that the cost of their prescription drugs was a burden for them. One way to maximize the benefits and minimize the harms of medications is through a comprehensive medication review (CMR). A CMR is an in-person, telephone, or video appointment, often with a pharmacist and a patient or caregiver, at which medications are reviewed, including how they are taken, their indications, side effects, potential for interactions, and costs. In December 2019, the NPHA asked adults aged 50 to 80 about their medication use and experiences having CMRs with pharmacists.

Two in five adults aged 50 to 80 (41%) reported taking two to four prescription medications, and 23% said they take five or more in addition to any nonprescription medications or supplements they may also take. Among those taking two or more prescription medications, 24% had ever had a CMR. A similar proportion of older adults who were enrolled in Medicare Part D prescription drug plans, which cover CMRs for eligible members, reported ever having a CMR (25%). Among adults aged 50 to 80 who had not had a CMR, the majority (86%) were unaware that their insurance might cover one, including 85% of those enrolled in a Medicare Part D prescription drug plan.

This poll shows that CMRs are an underutilized opportunity to help ensure medication regimens are as effective, safe, and affordable as possible. Clinicians can increase awareness about the benefits and availability of CMRs among older adults, including as a potential opportunity to address high health care costs, particularly those enrolled in Medicare Part D plans for whom such services may be covered.

As a treatment for bacterial infections, antibiotics can save lives. However, inappropriate use can reduce their effectiveness and lead to other harms. In May 2019, the NPHA asked adults aged 50 to 80 about their experiences with and opinions about antibiotics. Nearly half of adults aged 50 to 80 (48%) reported filling a prescription for antibiotics in the last 2 years.

Among those who filled a prescription for an antibiotic in the last 2 years, 13% reported having leftover medication.

Among those who kept leftover antibiotics, 60% said they did so in case they got another infection. A smaller proportion (6%) kept leftover antibiotics in case a family member got an infection, 4% were not sure how to dispose of the leftovers, and 2% forgot to dispose of them. In addition, among all respondents, 19% reported ever taking antibiotics without talking to a health care professional (17% took their own leftover medication and 3% took someone else’s medication).

While patients should be counseled to take all the antibiotics that are prescribed in order to appropriately treat their infection and minimize the emergence of resistance, some stop taking them. Across the population, this represents several million doses of leftover antibiotics. Use of these leftover antibiotics without medical supervision could result in serious drug interactions and other side effects, and could also contribute to increased antibiotic resistance.

To help ensure that antibiotic use is appropriate, safe, and effective, clinicians should give careful consideration to the number of pills given, so that excess medication does not contribute to misuse. Patients should be counseled about the risks of taking antibiotics without consulting a health care professional, and patients and family members should be encouraged to bring leftover antibiotics to community “take back” events or follow other guidelines for disposal.

Health conditions and procedures that result in pain are more common as people age. In March 2018, the NPHA asked adults aged 50 to 80 about their use of opioids for pain management, the education they received, how they disposed of unused medications, and perceptions of current and proposed policies related to opioid disposal and prescribing.

Overall, 29% of respondents said they filled a prescription for an opioid pain medication for themselves within the past 2 years. As summarized in Figure 21-1, 90% said they talked with the prescribing health care provider about how often to take the pain medication. However, fewer said they talked about side effects, when to reduce the amount of medication, risk of addiction, risk of overdose, and what to do with leftover pills. Among those who were prescribed an opioid, half said they had medication left over

(49%). When asked what they did with extra pain medication, 86% said they kept it in case they had pain again.

FIGURE 21-1. Opioids. (Courtesy from National Poll on Healthy Aging. University of Michigan https://www.healthyagingpoll.org/reports-more/report/older-adults-experiences-opioid- prescriptions.)

Health care providers who prescribe and dispense medications should discuss how and why to safely use and dispose of medications in language that patients understand. In addition to providing recommendations for safe storage and disposal, they should help patients in identifying where and how they will dispose of extra medication.

A quarter of older adults did not try to take less pain medication and half did not switch to a non-opioid medication as soon as possible, illustrating missed opportunities to reduce opioid use that should be addressed.

Therefore, it is critically important that clinicians work with patients to identify pain management strategies that will address pain while minimizing the risks of opioid medications. Since there are effective nonopioid medication and nonmedication strategies to treat pain for a variety of conditions, the opioids should not be the first-line treatment for most pain conditions.

As an increasing number of US states have legalized marijuana, there has been an upward trend in marijuana use among older adults. In October 2017, the NPHA asked adults aged 50 to 80 about marijuana use for medical purposes, its perceived benefits, perception of how marijuana compares to

prescription pain medicine, and support for marijuana-related policies. Overall, 6% of poll respondents reported using marijuana for medical purposes and 18% indicated they know someone personally who uses marijuana for medical purposes.

One in five older adults (21%) reported that their primary health care provider has asked whether they use marijuana. As shown in Figure 21-2, 70% of respondents expressed an interest in speaking to their provider about uses of marijuana for medical purposes and only 13% expressed no interest in doing so.

FIGURE 21-2. Marijuana. (Courtesy from National Poll on Healthy Aging. University of Michigan https://www.healthyagingpoll.org/reports-more/report/older-adults-perspective- medical-marijuana.)

When asked about the benefits of medical marijuana, 31% felt that marijuana definitely provides pain relief, another 38% believed it probably does, 27% were unsure, while 4% said they believed marijuana does not provide pain relief. When comparing marijuana with prescription medications for treating pain, 48% indicated that they felt prescription pain medication was more effective than marijuana, 14% thought marijuana was more effective, and 38% said they considered marijuana and prescription pain medication to have about the same effectiveness. About half of respondents (53%) thought the government should develop rules to standardize medical marijuana dosing and 64% felt the government should fund research to study the health effects of marijuana.

These findings suggest that more screening as well as rigorous studies on the health effects and safety of marijuana use may be needed, especially in

Romantic relationships are important to well-being and quality of life at any age. While sex is an integral part of the lives of many older adults, this topic remains understudied and infrequently discussed. In October 2017, the NPHA asked adults aged 65 to 80 about their perspectives on relationships and sex and their experiences related to sexual health.

Two in five (40%) adults aged 65 to 80 indicated that they are currently sexually active, and 54% of those are in a romantic relationship (Figure 21- 3). Sexual activity decreased with age (46% age 65–70, 39% age 71–75, and 25% age 76–80). Most older adults (76%) agreed that sex is an important part of a romantic relationship at any age (see Figure 21-3). Yet only 17% reported speaking with their health care provider about their sexual health in the past 2 years. Of those who had talked with their health care provider, 60% initiated the conversation themselves.

FIGURE 21-3. Sexual health. (Courtesy from National Poll on Healthy Aging. University of Michigan https://deepblue.lib.umich.edu/bitstream/handle/2027.42/143212/NPHA-Sexual-Health- Report_050118_final.pdf?sequence=1&isAllowed=y.)

Clinicians should inquire about and offer opportunities to discuss sexual health with their older patients, regardless of age or health status. Raising the topic can help older adults to better understand and address issues related to this important component of overall health and quality of life. A more

detailed discussion of this topic is provided in Chapter 35 (women’s sexuality) and Chapter 37 (men’s sexuality).

Although urinary incontinence is common among older women, embarrassment about urine leakage or the belief that incontinence is a normal part of aging may prevent women from seeking treatment. In March 2018, the NPHA asked women aged 50 to 80 about their experiences with urinary incontinence and related discussions with their doctors.

Nearly half of older women (46%) reported urinary incontinence in the past year. Of women reporting urinary incontinence, 41% described leakage as a problem, and 31% had leakage episodes almost daily. The most common strategies used to manage urinary incontinence are summarized in Figure 21-

4. Overall, 34% of older women who experienced incontinence said they spoke to their doctor about urinary leakage (28% for those aged 50–64 and 44% among those aged 65–80). Women who viewed incontinence as a problem or felt embarrassed by it were more likely to have sought medical advice.

FIGURE 21-4. Urinary incontinence. (Courtesy from National Poll on Healthy Aging. University of Michigan https://www.healthyagingpoll.org/reports-more/report/urinary- incontinence-inevitable-part-aging.)

What prevented women from seeking medical treatment for urinary incontinence? Among women with incontinence, 66% said they had not

spoken to their doctor because they felt the problem was not that bad, 23% said they had other things to discuss, and 22% did not see urinary incontinence as a health problem. Another 15% of women said their doctor had not asked about urinary incontinence, 10% were uncomfortable discussing urinary leakage, and 4% did not think the doctor could help.

These poll results suggest that while urinary incontinence is experienced by nearly half of older women, most manage their symptoms without support or input from their health care providers and many do not seek treatment because they prioritize other medical issues or they do not consider urinary incontinence to be a health problem. Yet, any urine leakage can diminish quality of life, and incontinence that prevents women from participating in health-promoting behaviors such as exercise can have a negative impact on overall health. Screening for urinary incontinence can help to identify patients who may benefit from education or services to address their urinary incontinence which can have important implications for health and quality of life.

Oral health is an integral part of overall health. Keeping teeth healthy involves a combination of good oral hygiene and routine preventive dental care with prompt attention to dental problems before they become severe. In April 2017, the NPHA explored oral health and experiences with dental care and coverage among adults aged 50 to 64.

More than one in four adults (28%) reported that their oral health was fair or poor. One in three (34%) said they were embarrassed about the condition of their teeth, and a similar percentage reported that they have experienced dental pain or problems in the past 2 years. One in five (19%) said it had been more than 5 years since their last preventive dental visit.

More than one in four respondents (27%) reported that they needed dental care in the past 2 years but either delayed or did not get care. Among those with unmet dental needs, 69% cited cost as a major factor. Being afraid of the dentist (20%), finding time to go (18%), and finding a dentist (14%) also contributed to unmet dental needs.

Overall, 28% of adults aged 50 to 64 indicated they did not currently have dental coverage. Many respondents expressed uncertainty about their insurance coverage for dental care when they turn 65: 51% did not know how they will get dental insurance when they turn age 65 and 13% thought

that traditional Medicare would provide their dental coverage even though traditional Medicare’s coverage of dental services is limited to narrowly defined medically necessary dental services only.

Recognizing that oral health is integral to good health at every age and that adults in older age groups can have unique oral health needs and barriers to accessing dental care, in December 2019, the NPHA asked adults aged 65 to 80 about oral health, dental care utilization and access, dental coverage, and their perspectives on proposed changes to Medicare to cover dental care.

Overall, 25% of adults aged 65 to 80 rated their oral health as fair or poor and 24% reported having dentures. In addition, 46% of those age 65 to 80 said they were missing teeth for which they did not have dentures or implants, and 27% said they were embarrassed by the condition of their teeth. In the past 2 years, 20% said they had experienced dental pain and the same percentage reported problems with eating and chewing. Nearly half (47%) of respondents reported that they do not have dental coverage.

The condition of one’s teeth can affect self-esteem, social relationships, job seeking and retention, ability to maintain good nutrition, and overall health. Both polls found poorer oral health status and lower use of dental services among those with self-reported fair or poor physical or mental health. People with chronic health conditions and disabilities may face challenges maintaining oral hygiene and getting dental care, and medications can contribute to dry mouth which can negatively affect oral health. Oral health problems can also negatively affect physical and mental health. For example, dental pain or problems with eating and chewing may lead to difficulty maintaining a healthy diet. Clinicians should encourage patients to prioritize their oral health and be aware of accessible, lower cost options for dental care in their communities.

“Low value” health care services, including medications, tests, and procedures that are unlikely to improve health outcomes, are not only unnecessary and wasteful, but may also create potential harms for patients. In October 2017, the NPHA asked adults aged 50 to 80 about their perspectives on health care services that may not be needed.

Only 14% of older adults agreed that “when it comes to medical treatment, more is usually better.” However, older adults’ own experiences

suggest overuse is common: 25% agreed that their own health care provider often recommends medications, tests, or procedures that they do not think they really need. More than half (54%) agreed that health care providers in general often recommend medications, tests, or procedures that patients do not really need.

Conventional wisdom has suggested that patients’ preferences drive overuse of low-value health care services. Results of this poll suggest that health care providers may be making incorrect assumptions about their patients’ desire for services that have limited clinical value.

As COVID-19 began to spread across the United States in early 2020, health systems made rapid and sweeping changes to how care was delivered. These changes and the risk of COVID-19 required many older adults to have appointments with their health care providers through telehealth rather than in-person visits. In May 2019 and June 2020, the NPHA asked adults aged 50 to 80 about their use of and perspectives on telehealth.

In May 2019, 14% of older adults said that their health care providers offered telehealth visits, compared to 62% in June 2020. Similarly, the percentage of older adults who had ever participated in a telehealth visit rose dramatically from 4% in May 2019 to 30% in June 2020.

In June 2020, 30% of older adults with a telehealth visit said that video or phone visits were the only options available when scheduling their appointment. Nearly half (46%) indicated that in-person visits were canceled or rescheduled to telehealth visits by their health care provider. Fear of COVID-19 led 15% to request or reschedule an in-person appointment as a telehealth visit.

Poll results demonstrate that the availability, use, and interest all increased substantially over 1 year, as did the personal use of and comfort with video-conferencing technologies commonly used in telehealth visits. As more older adults experienced telehealth visits, some perceived concerns, including privacy and communication with health care providers, diminished. Perceptions about the overall convenience of telehealth visits also increased.

As use of telehealth continues to increase, clinicians should be aware of the challenges and concerns some older patients have with virtual visits, as summarized in Figure 21-5. Importantly, while the vast majority of older adults who had a telehealth visit reported that the technology was easy to use, some older adults have limited experience and comfort with technology and may need additional support. Furthermore, some older adults were concerned about the quality of care compared to in-person visits and about not being able to get a physical examination. Until these concerns are addressed, some older adults may be hesitant to seek health care in this format.

FIGURE 21-5. Telehealth. (Courtesy from National Poll on Healthy Aging. University of Michigan https://www.healthyagingpoll.org/reports-more/report/telehealth-use-among-older- adults-and-during-covid-19.)

Patient portals have become the preferred form of communication with patients for many health care practices. In March 2018, the NPHA asked older adults aged 50 to 80 about their experiences with patient portals. About half of older adults (51%) reported they have set up a patient portal. There were demographic differences, with higher proportions setting up a patient portal among women versus men (56% vs 45%), among adults with some college versus high school only (59% vs 40%), and among those with higher versus lower annual household income (59% for = $60,000 vs 42% for <

Interestingly, there were similar rates of portal use for those aged 50 to 64 (52%) and 65 to 80 (49%). Older adults aged 65 to 80 identified technology barriers and lack of comfort as key reasons for not setting up a portal. In contrast, adults aged 50 to 64 report few specific barriers, but simply reported not taking the time to set one up. Eliminating barriers to setup and use of patient portals, while maintaining the option to continue telephone communication, may be the appropriate strategy to meet the varied needs of older adults.

Each year in the United States, adults aged 50 and older make more than 40 million visits to an emergency department (ED). In June 2020, the NPHA asked adults aged 50 to 80 about their ED experiences. Overall, 26% of adults aged 50 to 80 reported having an ED visit in the past 2 years (32% for respondents aged 65–80 and 23% for those aged 50–64). Almost half of adults with self-reported fair or poor mental (46%) or physical (45%) health had an ED visit in the past 2 years.

When deciding whether to go to the ED, most aged 50 to 80 reported that they would be concerned about wait times (91%), exposure to COVID-19 (86%), out-of-pocket costs (79%), and being admitted to the hospital (77%); 37% said they would be concerned about transportation home. Nearly two in three older adults (63%) said they would first ask their health care provider or office staff before going to the ED. One in eight (13%) said they went to the ED because they could not get a timely primary care or specialty care appointment.

When considering where to go for ED care, older adults reported that their insurance coverage (86%), the reputation of the ED (69%), location (68%), and a recommendation by a health care provider (61%) were very important factors. Overall, 80% of adults aged 50 to 80 were concerned about the costs of a future ED visit and 18% were not confident about being able to afford out-of-pocket costs for a future ED visit. Seven percent of older adults reported that they did not go to the ED when they thought they needed to due to concerns about their out-of-pocket costs.

These poll results could help hospitals, emergency and other health care providers, and insurers improve the ways they advise older adults on seeking emergency care, treat them once they arrive at the ED, address their cost- related concerns, and assist them in receiving follow-up care.

As Americans approach retirement age and eligibility for Medicare coverage, many face difficult decisions about their health insurance and its associated costs. In October 2018, the NPHA asked adults aged 50 to 64 about their current and future plans for their health insurance coverage, medical care, and employment.

Overall, 27% had little or no confidence in being able to afford the cost of their health insurance over the next year and 45% had little or no confidence in being able to afford the cost of their health insurance when they retire. In the previous year, 11% of adults aged 50 to 64 reported thinking about going without health insurance, and an additional 5% decided to go without health insurance. In the previous year, 13% of adults aged 50 to 64 did not get medical care because of its high cost.

Adults aged 50 to 64 also reported making decisions about the timing of their retirement based on health insurance–related considerations. In the past year, 14% reported keeping a job specifically to have health insurance through their employer and 11% delayed or considered delaying retirement specifically to have employer-sponsored health insurance. Overall, 19% either kept a job, considered delaying retirement, or delayed retirement to keep their employer-sponsored health insurance.

Clinicians and patients should discuss the out-of-pocket costs of health care which can help to inform decisions about health insurance options and the timing, choice, and appropriateness of health care services.

Advance care planning, which often includes legal documentation of a medical durable power of attorney and an advance directive, helps ensure people receive medical care that is consistent with their values, goals, and preferences. In June 2020, the NPHA asked adults aged 50 to 80 about their advance care planning before and during the early months of the COVID-19 pandemic.

Overall, 59% said they have talked to someone (ie, a spouse, adult children, other family, or friends) about the types of medical care they want or do not want if they become seriously ill (Figure 21-6). People aged 65 to 80 were more likely than those aged 50 to 64 (70% vs 51%) and women were more likely than men (62% vs 55%) to have talked to someone about their care preferences.

FIGURE 21-6. Advance care planning. (Courtesy from National Poll on Healthy Aging. University of Michigan https://www.healthyagingpoll.org/reports-more/report/older-adults- experiences-advance-care-planning.)

Also shown in Figure 21-6, nearly half of older adults (46%) reported they had completed at least one advance care planning legal document (ie, a medical durable power of attorney or advance directive). Among the 54% of older adults who had not completed an advance care legal document, 62% said they had not gotten around to it, 15% did not know how, 13% said they do not like talking about these things, 13% did not think it necessary, 9% said no one asked them to, and 7% were deterred by cost.

Clinicians can help to encourage and facilitate these vital discussions about and documentation of preferences for medical care in the event of serious illness, as well as remind patients of the importance of regularly reviewing previous advance care plans to confirm they remain accurate.

Ageism is prevalent, and older adults may experience ageism in their day-to- day lives. In December 2019, the NPHA asked adults aged 50 to 80 about their experiences with different forms of everyday ageism, positive views on aging, and health. The nine forms of ageism explored through this poll were organized into three categories: (1) exposure to ageist messages, (2) ageism in interpersonal interactions, and (3) internalized ageism (personally held beliefs about aging and older people), as summarized in Table 21-2.

TABLE 21-2 ¦ NINE FORMS OF EVERYDAY AGEISM AND THEIR PREVALENCE AMONG ADULTS AGED 50–80A

Two in five older adults (40%) reported often or sometimes experiencing three or more (out of the nine) forms of everyday ageism. Experiencing three or more forms was more common among those aged 65 to 80 as compared to those aged 50 to 64 (49% vs 35%), women compared to men (43% vs 38%),

and those with annual household incomes below $60,000 compared to those with higher incomes (50% vs 33%). Being retired and living in a rural area were also associated with experiencing more forms of ageism.

Older adults who reported experiencing three or more forms of everyday ageism in their day-to-day lives had worse physical and mental health than those who reported fewer forms of ageism. For example, older adults who reported three or more forms of ageism were less likely to rate their overall physical health as excellent or very good compared to those reporting fewer forms (34% vs 49%). Older adults who experienced more forms of ageism were also more likely to have a chronic health condition such as diabetes or heart disease than those reporting fewer forms (71% vs 60%). Those who regularly experienced three or more forms of ageism were less likely than people who reported fewer forms to rate their mental health as excellent or very good (61% vs 80%) and more likely to report symptoms of depression (49% vs 22%).

Notably, older adults with positive views on aging reported experiencing fewer forms of everyday ageism and better physical and mental health.

Clinicians should be aware of how negative stereotypes, prejudice, and discrimination toward older people affect health and well-being and be part of efforts to challenge it and highlight positive views. Addressing everyday ageism may have far-reaching benefits for the health and well-being of older adults.

Food insecurity, defined as difficulty in acquiring or accessing food due to a lack of money, affected an estimated one in nine US households in 2018.

Although trends in food insecurity are tracked through surveys of the general US population, few surveys specifically focus on food insecurity among older adults. In December 2019 (prior to the COVID-19 pandemic), the NPHA surveyed adults aged 50 to 80 about household food insecurity and participation in food-assistance programs.

As summarized in Figure 21-7, 14% of respondents reported experiencing household food insecurity in the past year. Among older adults who experienced household food insecurity in the past year, 42% reported severe food insecurity, meaning individuals in their household reduced the quality or quantity of foods they consumed due to limited resources.

than adults aged 65 to 80 (10%), and higher among non-Hispanic Black adults (22%) and Hispanic adults (22%) compared to non-Hispanic White adults (12%). It was also more common among older adults with lower levels of education and lower household income.

FIGURE 21-7. Food insecurity. (Courtesy from National Poll on Healthy Aging. University of Michigan https://www.healthyagingpoll.org/reports-more/report/how-food-insecurity-affects- older-adults.)

As shown in Figure 21-7, household food insecurity was associated with lower self-reported physical and mental health. Nearly half of adults ages 50 to 80 who were food insecure rated their physical health as fair or poor (45%), compared to 14% of those who were food secure. Almost a quarter of those who were food insecure reported fair or poor mental health (24%) compared to 5% of those who were food secure.

During the past year, 10% of respondents aged 50 to 80 reported receiving Supplemental Nutrition Assistance Program (SNAP) benefits. Adults aged 60 and older are eligible to receive home-delivered or congregate meals (eg, meals delivered in community or group settings) through the Older Americans Act. Yet among adults 60 and older, only 2% reported participating in meal programs through a community or senior center, and 1% received meals delivered to their home from a program like Meals on Wheels in the past year.

These poll results suggest that some older adults experiencing food insecurity may not be benefitting from programs designed to support them. Barriers to participating in SNAP or other community programs can include lack of knowledge or misinformation about services or eligibility, complex

application procedures, waitlists, inadequate transportation, stigma, and other factors.

Improved communication about the benefits of participating in SNAP and community meal programs, as well as increased screening in clinical settings and referrals to community resources, may help to improve participation rates in nutrition programs and help alleviate food insecurity among older adults.

When natural disasters and other emergencies occur, some older adults, including those with chronic health conditions and impaired mobility, may be particularly vulnerable to adverse effects. In May 2019, the NPHA asked adults aged 50 to 80 about their experiences with disasters, emergency planning, and their preparedness for such events.

More than one in five of older adults (22%) had experienced an emergency or disaster such as a power outage lasting more than a day, severe weather, evacuation from their home, or a lockdown in the past year, while 73% reported experiencing at least one such event during their lifetime. As shown in Figure 21-8, among older adults who required essential medications or health supplies, 82% had a 7-day supply of medication and 72% had a 7-day supply of health supplies, but only half reported having a 7- day supply of food and water. Among the 9% of respondents who used essential medical equipment that requires electricity, 25% had an alternative power source. Less than half had signed up for emergency alerts or had spoken to family or friends about an evacuation plan (see Figure 21-8).

FIGURE 21-8. Emergency planning. (Courtesy from National Poll on Healthy Aging. University of Michigan https://www.healthyagingpoll.org/reports-more/report/emergency- planning-among-older-adults.)

More than half of older adults believed they will likely experience some type of natural disaster or emergency in the coming year and the majority generally felt confident in their ability to manage through them, yet these poll results suggest that many older adults have not taken key steps recommended by disaster preparedness agencies. Clinicians should discuss disaster preparedness with their older patients, particularly in areas that routinely face natural disasters.

Many older Americans live with pets and consider them part of the family. Pets can offer companionship and have a positive impact on health and well- being. In October 2018, the NPHA asked adults aged 50 to 80 about their pets and the benefits and challenges of owning a pet.

More than half of older adults (55%) reported having a pet. Among pet owners, the majority (68%) had dogs, 48% had cats, and 16% had a small pet such as a bird, fish, or hamster. More than half of pet owners (55%) reported having multiple pets.

Some possible health benefits of pets are included in Figure 21-9. Pet owners said that their pets help them enjoy life (88%), make them feel loved (86%), reduce stress (79%), provide a sense of purpose (73%), and help them stick to a routine (62%). Respondents also reported that their pets connect them with other people (65%), help them be physically active (64%

overall and 78% among dog owners), and help them cope with physical and emotional symptoms (60%), including taking their mind off pain (34%).

Among those who lived alone and/or reported fair or poor physical health, 72% said pets help them cope with physical or emotional symptoms.

While most pet owners reported positive experiences with their pets, some noted challenges. About one in five (18%) indicated that pet care puts a strain on their budget. One in six (15%) said that their pet’s health takes priority over their own health, and 6% reported that their pets caused them to fall or otherwise injure themselves.

These results suggest that pets can provide a myriad of benefits for older adults, including boosts to emotional and physical health while also potentially contributing to challenges for some people. Health care professionals should be aware of the important role that pets play in the lives of many older adults, as pets have the potential to help, or hinder, self-care and adherence to treatment plans.

Family caregivers play a vital role in providing support to older adults living with dementia and other cognitive impairments. In April 2017, the NPHA asked adults aged 50 to 80 who identified as caregivers about their experiences caring for a person with dementia.

Overall, 7% of poll respondents (n = 148) identified as a caregiver of a person age 65 or older with dementia, Alzheimer disease, or another cognitive impairment. The majority of caregivers (62%) were women; 60% provided care to a parent, 19% to a spouse, and 21% to another relative, friend, or neighbor. Most caregivers (60%) have been providing care for 1 to 5 years and 29% have been doing so for 5 years or more. Nearly half of caregivers (45%) were employed in addition to having caregiving responsibilities.

Most caregivers (85%) reported they find caregiving rewarding (45% very rewarding and 40% somewhat rewarding). A slightly lower percentage (78%) said they find caregiving to be stressful (19% very stressful and 59% somewhat stressful) and 62% reported they find caregiving both stressful and rewarding. Overall, 27% of caregivers had used caregiving resources in the past year such as self-help resources, family therapy, classes or trainings, support groups, and/or respite care; 41% of those who had not used any caregiving resources indicated an interest in using them.

More than a quarter of caregivers (27%) reported delaying or not doing things they should do for their health; 66% said caregiving interferes with their ability to take good care of themselves, go to the doctor when they have a health problem, spend time with family and friends, take care of everyday responsibilities, and/or keep up with work duties. Nearly three in four dementia caregivers (73%) had not used caregiving resources in the past year, and among those, 41% expressed an interest in using them.

These findings suggest that there are opportunities to provide more support to dementia caregivers. A first step in meeting their needs is that health care providers should ask about caregiving responsibilities as a routine part of clinical care. As the population ages and the number of available caregivers is unlikely to keep pace, it is critically important to ensure that resources to support dementia caregivers are readily available and accessible.

Chronic loneliness can adversely affect memory, mental and physical health, and longevity. The NPHA asked adults aged 50 to 80 about their feelings of lack of companionship and isolation (loneliness), social interactions, and health behaviors in June 2020 as a follow-up to a similar NPHA survey conducted in October 2018 among a different national sample. The follow-up

survey showed a substantial increase in loneliness among older adults from before the COVID-19 pandemic to the early months of the pandemic (March– June 2020).

As shown in Figure 21-10, two in five adults aged 50 to 80 reported feeling a lack of companionship (32% some of the time, 9% often) during the early months of the pandemic, compared to one-third (26% some of the time, 8% often) in 2018. In June 2020, 35% of older adults said they felt less companionship compared to before March 2020, 12% felt more, and 53% felt the same amount of companionship.

FIGURE 21-10. Loneliness. (Courtesy from National Poll on Healthy Aging. University of Michigan https://www.healthyagingpoll.org/reports-more/report/loneliness-among-older-adults- and-during-covid-19-pandemic.)

As shown in Figure 21-10, in June 2020, more than half of older adults reported feeling isolated from others (43% some of the time, 13% often) compared to one-quarter (22% some of the time, 5% often) in 2018. Nearly half of older adults in June 2020 reported infrequent social contact (once a week or less) with family, friends, or neighbors from outside the home, compared to one-quarter in 2018. When comparing their feelings in June 2020 to before the pandemic, about half of adults age 50 to 80 (48%) felt more isolated, 8% felt less isolated, and 44% reported feeling the same level of isolation.

Feeling a lack of companionship some of the time or often during the first 3 months of the pandemic was more common among women (47% vs 35% of men), people who lived alone (50% vs 39% who lived with others), and

those who were unemployed, disabled, or not working (52% vs 39% of those employed or retired). Others more likely to report a lack of companionship included those from households with annual incomes less than $60,000 (46% vs 38% of those with higher incomes) and caregivers (48% vs 40% of non- caregivers). In addition, feeling a lack of companionship was more common for those who reported fair or poor physical health (52% vs 39% of those reporting excellent, very good, or good physical health) or fair or poor mental health (68% vs 39% of those reporting excellent, very good, or good physical health), and more common for those reporting more symptoms of depression (84% vs 36% among those with fewer symptoms).

This poll demonstrates that a greater proportion of adults aged 50 to 80 felt a lack of companionship, felt socially isolated, and had infrequent contact with others from outside their home during the early months of the pandemic than in 2018 when those numbers were already worrisomely high. Loneliness and limited social contact during the pandemic were strongly associated with depressive symptoms and overall mental health among older adults. In addition, these results suggest that those who engage in healthy behaviors less frequently experience more loneliness than those who have a healthier lifestyle (eg, get regular exercise and enough sleep). Supporting patients in maintaining connections and initiating or maintaining healthy behaviors can have wide ranging health benefits and can be protective during times of stress and uncertainty.

Recommendations to slow the spread of COVID-19 included staying home when possible, isolating from others if symptoms develop, and getting outdoors to safely connect with other people and exercise. Yet where a person lives, their home and neighborhood, could influence peoples’ ability to follow these recommendations. In June 2020, the NPHA asked adults aged 50 to 80 about their living environments and behaviors during the pandemic.

Nearly one in five older adults who lived with others (18%) reported they do not have a place where they live to safely isolate if they were to contract COVID-19. Most adults ages 50 to 80 (85%) reported having an outdoor space (such as a balcony, patio, porch, or yard) to safely engage with their neighbors and community during the pandemic. Three in four older adults (72%) said they have a view of nature from inside their home. Two in

three (68%) noted they have a greenspace (such as a garden, park, or woods) within walking distance of their home.

Older adults who had access to an outdoor space to engage with their neighbors and community, a view of nature, or nearby greenspaces were more likely to engage in outdoor activities. In addition, older adults who did not have access to outdoor spaces, a view of nature, or nearby greenspaces were more likely to report feelings of loneliness, including a lack of companionship and feeling isolated from others, than those who had access to these features in their environment.

The characteristics of homes and neighborhoods can affect an individual’s ability to carry out public health recommendations to reduce the spread of COVID-19, contributing to disparities in infection rates. There are notable disparities by race and ethnicity, income, dwelling type, and health status. Some older adults are less likely to have access to outdoor spaces to engage with neighbors, views of nature, and nearby greenspaces, all of which are related to health-promoting activities beyond COVID-19. As a result, clinicians should take patient circumstances into consideration when providing recommendations.

Since 2017, the University of Michigan NPHA has provided a unique vehicle to amplify the voices of US adults aged 50 to 80 and identify and share opportunities to improve their health and health care. The findings summarized in this chapter come from a selection of prior NPHA reports.

Several common themes emerge from these reports, such as the vital importance of older adults’ primary care providers as trusted sources of information and guidance. While there are many existing time constraints during clinical encounters, particularly in geriatric medicine, the poll results highlight topics that are important to many patients but not always discussed by health care providers, such as sexual health, emergency preparedness, and the cost of prescription medications. Additionally, a number of factors outside of the walls of the health care system, such as social connections and the built environment, influence older adults’ day-to-day well-being and are important for clinicians to consider during encounters with older patients. In these and other contexts, there remain persistent disparities by education, income, and race/ethnicity, and recent trends in technology use (eg, patient portals and telehealth) have the potential to increase health inequities. Taken

together, the findings of the NPHA highlight critically important and timely opportunities for clinicians and policymakers to improve health care delivery, support health care access and decision making, and address social aspects of health for older US adults to optimize their overall well-being.

We acknowledge the support of Dianne Singer, MPH (production manager), and Matthias Kirch, MA (lead data analyst), of the University of Michigan National Poll on Healthy Aging. We also acknowledge Emily Smith, MA (multimedia designer).

Agochukwu-Mmonu N, Malani PN, Wittmann D, et al. Interest in sex and conversations about sexual health with health care providers among older

Bell SA, Singer D, Solway E, Kirch M, Kullgren J, Malani P. Predictors of emergency preparedness among older adults in the United States.

Chen J, Malani P, Kullgren J. Patient Portals: Improving the health of older adults by increasing use and access. Health Affairs Blog. Electronically published September 6, 2018.

Feldman SJ, Solway E, Kirch M, Malani P, Singer D, Roberts JS. Correlates of formal support service use among dementia caregivers. J Gerontol

Harbaugh CM, Malani P, Solway E, et al. Self-reported disposal of leftover opioids among US adults 50-80. Reg Anesth Pain Med.

Leung CW, Kullgren JT, Malani PN, et al. Food insecurity is associated with multiple chronic conditions and physical health status among older US adults. Prev Med Rep. 2020;20:101211.

Malani P, Solway E, Kirch M, Singer D, Kullgren J. Use and perceptions of antibiotics among US adults aged 50–80 years. Infect Control Hosp Epidemiol. 2021;42(5):628–629.

Maust DT, Solway E, Langa KM, et al. Perception of dementia risk and preventive actions among US adults aged 50 to 64 years. JAMA Neurol. 2020;77(2):259–262.

Scherer AM, Solway E, Malani PM, et al. Factors associated with health insurance affordability concerns among U.S. adults age 50–64: a cross- sectional, nationally representative study. J Gen Intern Med.

Tipirneni R, Solway E, Malani P, et al. Health insurance affordability concerns and health care avoidance among US adults approaching retirement. JAMA Netw Open. 2020;3(2):e1920647.

Special Management Issues

Paula A. Rochon, Sudeep S. Gill, Christina Reppas- Rindlisbacher, Nathan M. Stall, Jerry H. Gurwitz

Prescribing for older adults presents special challenges. Older people take about three times as many prescription medications as do younger people, mainly because of an increased prevalence of chronic medical conditions among the older population. Taking several drugs together substantially increases the risk of drug interactions and adverse events, and older women are more likely than men to experience an adverse drug event (ADE).

While a provider can usually do little to alter the characteristics of individual older adults to affect the kinetics or dynamics of drugs, the decision whether to prescribe any drug, the choice of drug, and the manner in which it is to be used (eg, dose and duration of therapy) are all factors that are largely under the control of the provider. This chapter discusses ways to optimize prescribing of drug therapy for older women and men.

Writing a prescription is the most frequently employed medical intervention. Yet, creating optimal drug regimens that meet the complex needs of older adults requires careful thought and planning. Multiple factors contribute to inappropriate drug prescribing, including lack of adequate training of providers in safe prescribing practices, and in prescribing for older adults.

Further, a lack of routine use of safe medication prescribing practices, such as checking drug allergies, confirming appropriate drug doses, adjusting doses for renal impairment, and potential drug–drug interactions and medication reconciliation, also contribute to prescribing errors. Avoidable ADEs are the most serious consequences of inappropriate and unsafe drug prescribing. The possibility of an ADE should always be borne in mind when evaluating an older individual. A valuable maxim in geriatric medicine posits that when evaluating virtually any new symptom in an older patient, the possibility of an ADE should be considered in the differential diagnosis. Female sex, advanced age, frailty, cognitive impairment, and increased drug utilization are all factors that contribute to an individual patient’s risk for developing a drug-related problem. US data indicate that older adults in the community are up to three times more likely to have an ADE that requires evaluation in an outpatient setting or in an emergency department and are seven times more likely to require a hospital admission. In the inpatient setting, older adults account for more than 50% of hospitalizations complicated by an ADE. In the nursing home setting, the incidence of ADEs approaches 10 per 100 resident-months, of which over half may be preventable. These estimates are probably conservative because preventable ADEs were strictly defined and it was assumed that, in many cases, the prescription of the offending drug was indicated, and the ADE was therefore not preventable.

Herbal medicines are frequently used by older adults, and physicians often do not question patients about such use. An estimated 22% of the US adult population takes an herbal medicine or supplement such as ginseng, ginkgo biloba extract, and glucosamine. In one survey, almost 75% of patients did not inform their physician that they were using unconventional treatments including herbal medicines. Herbal medicines may interact with prescribed drug therapies leading to adverse events, underscoring the importance of routinely questioning patients about their use of these therapies. Examples of herbal–drug therapy interactions include warfarin in combination with ginkgo biloba extract leading to an increased risk for bleeding and serotonin-reuptake inhibitors in combination with St. John’s Wort leading to serotonin syndrome.

When prescribing medications to older adults, it is important to consider pharmacokinetic and pharmacodynamic changes observed with aging and differing by sex. Age-related pharmacologic changes combined with sex related changes, and medical conditions that are more common in older adults can impact the pharmacokinetics of drug therapies. Understanding these issues can help to guide prescribing decisions.

Traditionally, pharmacokinetics involves consideration of drug absorption, distribution across body compartments, metabolism, and elimination. Drug absorption is largely unchanged with aging. Changes in drug distribution, metabolism, and excretion can impact the clearance of a medication from the body in older adults. Age-related changes in body composition can affect the volume of distribution of a drug. With advancing age, older people have less lean body mass and greater fat stores relative to younger people. These age-

related changes may affect women more than men. As such, drug therapies such as benzodiazepines which are highly lipid-soluble have an increased volume of distribution in older people relative to those who are younger.

Much of the literature on age-related changes in drug metabolism has focused attention on reduced oxidative metabolism by the family of cytochrome P450 (CYP450) isoenzymes in the liver. The activity of various CYP450 isoenzymes can be inhibited or induced by a wide range of medications, which contributes to numerous drug-drug interactions. In addition, elimination of many drug therapies occurs through renal clearance, and renal function declines with age. Taken together, these age-related changes in pharmacokinetics have substantial impact on the clearance of many medications commonly used in older adults. Conventional wisdom and prudent prescribing practice warrants that special care be taken in drug dosing for older patients, particularly in the case of highly lipid soluble drugs, medications metabolized via reactions catalyzed by CYP enzymes, and renally excreted drugs. It is important to consider both age- and sex- related issues.

In contrast to pharmacokinetics, pharmacodynamics relates to the effect that a drug has on the body. Age and female sex are associated with enhanced sensitivity to a number of drug therapies. For example, older people may be more sensitive to the effects of benzodiazepines, opioids, and warfarin, exclusive of age-related pharmacokinetic changes that might exist. Older women may be even more sensitive to men to some drug therapies. This highlights the importance of integrating sex and age information when exploring pharmacodynamics and pharmacokinetics and making prescribing decisions for older women and men.

The science of geriatric pharmacology remains to be fully elucidated. A dogmatic approach to applying currently accepted principles of geriatric pharmacology in prescribing medications to older adults is not ideal. For example, the risk of fall-related injuries in older adults prescribed short half- life benzodiazepines and so-called “Z-drugs” (eg, zolpidem) may actually be similar to that of long-half-life benzodiazepines. These observations are clearly at odds with what would be expected based on the pharmacologic changes that occur with aging. Schwartz has written that “clinical factors such as disease, concomitant medications, lifestyle, diet, and nutraceutical intake may have greater effects and lead to greater variability in drug

clearance and effects than would be estimated based on investigations of pure aging or sex effects in animal or human studies.”

Various strategies may assist in formulating the most appropriate and individualized drug dose for older patients. These approaches may include weight-based and renal-based dosing. Individualized dosing of renally cleared medications, particularly those with a narrow therapeutic index, is facilitated by the provision of estimates of glomerular filtration rates now routinely added to the results of laboratory panels. In addition, clinical decision support tools are commonly incorporated into electronic health records to assist in the choice of medication dose when ordering for patients with reduced renal function. Finally, while controversy remains concerning the clinical utility and practicality of applying pharmacogenetic data to the direct care of older patients (eg, to guide warfarin dosing), pharmacogenetic- dosing holds both the promise and potential for enhancing the safety and effectiveness of geriatric pharmacotherapy in the future.

Various criteria and frameworks have been developed by experts internationally to assess the quality of medication use in older populations. These criteria generally comprise a list of drugs that are potentially inappropriate for use in older adults or highlight medications that should be considered in older people with certain indications. Criteria such as Beers and STOPP/START are designed to assist with clinical decision making and should be applied while considering patient preferences and using other tools such as clinical pharmacy interventions and computerized alerts.

One of the most widely employed approaches for the assessment of inappropriate prescribing are the Beers Criteria. These criteria, initially developed in 1991 by a consensus panel of experts in geriatric medicine, geriatric psychiatry, and pharmacology, have been updated and revised a number of times over the years and most recently in 2019. Use of drug therapies considered inappropriate according to the Beers Criteria has been identified as an ongoing issue of widespread concern across all clinical settings. The 2019 Beers Criteria update was sponsored by the American Geriatrics Society and involved a panel of 13 experts in geriatric care and pharmacology following an evidence-based approach. The aim of the 2019

update was to use a comprehensive, systematic review and grading of the evidence on drug-related problems and adverse events in older adults. The 2019 update retained each of the five criteria from 2015: (1) medications that are potentially inappropriate in most older adults, (2) those that should typically be avoided in older adults with certain conditions, (3) drugs to use with caution, (4) drug-drug interactions, and (5) drug dose adjustment based on kidney function.

A different approach to facilitating medication review in older adults is the STOPP (Screening Tool of Older Persons potentially inappropriate Prescriptions) and START (Screening Tool to Alert to Right Treatment) criteria. The STOPP criteria were initially developed in 2008 in Ireland using a Delphi consensus method with experts in geriatric medicine, clinical pharmacology, clinical pharmacy, geriatric psychiatry, and primary care.

These criteria identify common instances of potentially inappropriate prescribing including drug-drug and drug-disease interactions, drugs that adversely affect those at risk for falls and duplicate drug class prescriptions. The criteria are organized by organ system, and the reason for each of the prescribing concerns is explained. The prevalence of older patients with at least one potentially inappropriate prescription identified using the STOPP criteria ranges from 21% to 39% in the primary care setting, from 26% to 77% in the hospital setting, and from 23% to 70% in nursing homes. The STOPP criteria’s potentially inappropriate medications have been associated with avoidable ADEs in older people that contributed to acute care hospitalization. Version 2 of the STOPP criteria was published in 2015 and provides guidance on prescribing indicators (Table 22-1) along with a list of 80 evidence-based potentially inappropriate prescriptions for older adults, categorized by body system.

TABLE 22-1 ¦ SCREENING TOOL OF OLDER PERSONS’ PRESCRIPTIONS (STOPP) VERSION 2

It is important to consider the cumulative burden of prescribing a combination of drugs with anticholinergic effects rather than view them individually. Drugs with anticholinergic effects are commonly prescribed to patients with conditions ranging from depression to urinary incontinence to neuropathic pain and migraine headaches. These therapies raise concerns for older patients because they are associated with serious adverse events including confusion, urinary retention, and constipation. The cumulative burden of anticholinergic agents may more accurately reflect the risk for development of these adverse events. A number of scales have been identified to measure anticholinergic burden. These scales assign points to commonly prescribed anticholinergic drug therapies based on the risk for developing anticholinergic adverse events. In a recent review of these scales, the Drug Burden Index was the most commonly used scale or tool in community and database studies, while the Anticholinergic Risk Scale was used more frequently in care homes and hospital settings. In a study of geriatric evaluation and management in the primary care setting, it was found that higher Anticholinergic Risk Scores were associated with an increased risk for anticholinergic-related adverse events including falls, confusion, dry mouth, and constipation.

A concern with using a limited list of “inappropriate” drug therapies like the Beers Criteria relates to the extent that such a list fully captures the spectrum of drug-related problems likely to befall older patients. For example, studies of older patients presenting to US emergency departments

for ADEs or of ADEs in older patients recently discharged from the hospital have suggested that the Beers Criteria drugs capture only a very small fraction of the medications implicated in these events. The majority of these agents are not included among Beers Criteria medications. Furthermore, only a minority of Beers Criteria and STOPP/START criteria recommendations are based on high-quality evidence, attesting to the dearth of pharmacologic and drug safety and effectiveness research that directly focuses on the older population. A 2013 report issued by the US Department of Health and Human Services on the creation of a national action plan for ADEs prevention highlighted the need to explore strategies to improve medication prescribing more broadly. This report identified older adults as one of the most vulnerable groups for the development of ADEs. The action plan identified three classes of drug therapies that were associated with the highest risk for the development of ADEs. These were anticoagulants leading to bleeding, opioids leading to delirium and mental status changes, and insulin leading to hypoglycemia.

Ultimately, many different factors contribute to making the best prescribing decisions for the individual patient. In order to remain clinically valid, prescribing appropriateness criteria must be regularly updated to keep up with the evolving clinical evidence and ever-increasing number of new medications. Appropriate prescribing also needs to consider time-to-benefit, which takes into account a patient’s life stage and frailty and goes well beyond simply knowing the patient’s chronologic age. What remains essential is the need for ongoing assessment of the medication regimen in light of the individual’s clinical status, goals of care, and balancing of the risks and benefits of each medication.

A particularly concerning aspect of suboptimal medication use in older adults relates to the occurrence of prescribing cascades. The prescribing cascade concept was created by Rochon and Gurwitz in 1997 and updated in 2017. A prescribing cascade begins when a drug side effect is misinterpreted as a new medical condition. An additional drug therapy is prescribed, and the patient is placed at risk for the development of additional side effects relating to this potentially unnecessary treatment (Figure 22-1). Prescribing cascades and other risks associated with drug therapy are particularly

important for older adults with multiple chronic conditions who are likely to be prescribed multiple drug therapies. Prescribing cascades are now part of the definition of potentially inappropriate prescribing and have been included in numerous deprescribing processes.

FIGURE 22-1. The prescribing cascade. (Reproduced with permission from Rochon PA, Gurwitz JH. The prescribing cascade revisited. Lancet. 2017;389[10081]:1778–1780.)

Selected examples of prescribing cascades are described below and summarized in Table 22-2.

TABLE 22-2 ¦ EXAMPLES OF PRESCRIBING CASCADES

There has been concern that calcium channel blockers (CCB) used for the management of hypertension may lead to the development of edema. This drug-related side effect may in turn be misdiagnosed as a new medical condition and treated with a further drug therapy.

This association was explored in a cohort of more than 41,000 older adults with hypertension who were 66 years or older in a population-based study in Canada’s most populous province of Ontario. The population-based association between the initiation of a CCB and the initiation of a diuretic therapy was demonstrated. Those who were newly dispensed a CCB had an increased risk for being dispensed a loop diuretic compared to those who were newly dispensed other antihypertensive medications or an unrelated drug therapy. This is an important prescribing cascade given that CCBs are so widely prescribed, and it highlights the importance of raising awareness of this prescribing cascade to clinicians.

Antipsychotics, Parkinsonism, and Anti-Parkinson Therapy Initiation Antidopaminergic-related adverse effects associated with antipsychotic agents have long been recognized, including the development of extrapyramidal signs and symptoms. This drug-related symptom may be potentially misdiagnosed as a new medical condition (ie, Parkinson disease).

The association between antipsychotic drug exposure and subsequent treatment of parkinsonism was identified among 3512 adults aged 65 to 99 who were enrolled in a Medicaid program and initiated on a drug therapy for the treatment of parkinsonian symptoms. Patients dispensed a typical antipsychotic therapy or clozapine in the 90 days prior to the initiation of anti-Parkinson therapy were more than five times more likely to begin anti- Parkinson therapy relative to control patients who were not dispensed antipsychotic therapy. Furthermore, a dose–response relationship was demonstrated.

Antipsychotic therapy is widely used in older adults for the management of the behavioral and psychological symptoms of dementia. One of the initial studies to explore the association between atypical antipsychotic drug therapy and the development of parkinsonism demonstrated that these newer agents were also associated with parkinsonism and that this was in a dose- related fashion. Patients who are placed on anti-parkinsonian therapy then become vulnerable to the adverse events associated with this added therapy, including orthostatic hypotension and delirium. A better approach may be to

discontinue or reduce the dose of the antipsychotic therapy. If an antipsychotic is deemed essential, it may be prudent to try to select a therapy with less potent anti-dopaminergic blockade and to use this therapy at the lowest possible dose.

Drug-induced parkinsonism has also been reported with other anti- dopaminergic therapies, including metoclopramide. Such drug-induced symptoms in an older adult can be misinterpreted as indicating the presence of a new disease or be attributed to the aging process rather than to the drug therapy. This misinterpretation is particularly likely when the symptoms are indistinguishable from an illness, such as Parkinson disease, which has a greater prevalence in older adults.

Cholinesterase Inhibitors, Urinary Incontinence, and Anticholinergic Therapy Initiation

Cholinesterase inhibitors (such as donepezil, rivastigmine, and galantamine) are often prescribed to manage the symptoms of Alzheimer disease and related dementias. Through their effects on the autonomic nervous system, cholinesterase inhibitors can sometimes precipitate urge urinary incontinence. However, new-onset or worsening urge incontinence is also commonly seen as part of the natural history of dementia. Thus, clinicians may misinterpret incontinence in patients with dementia as an unavoidable progression of their underlying disease, when it may in fact represent a potentially reversible drug-related adverse event. A population-based cohort study demonstrated that cholinesterase inhibitor use was associated with an increased risk for receiving anticholinergic medications to manage urinary incontinence, suggesting that the use of anticholinergic drugs in patients with dementia may sometimes represent an unrecognized ADE related to cholinesterase inhibitor use. In addition, the use of anticholinergic drugs by older adults with dementia may expose them to anticholinergic adverse effects (such as urinary retention and postural hypotension) and may also counter the potential neurocognitive benefits of cholinesterase inhibitor treatment.

Other prescribing cascade scenarios, such as the association between the use of hydrochlorothiazide therapy and the initiation of anti-gout therapy or the use of NSAID therapy and antihypertensives, have been identified.

Prescribing cascades only become apparent and preventable when health care providers carefully consider the relationship between the initiation of a

new drug therapy, the adverse event profile of that therapy, and the development of a new symptom.

Given the risk and harms of prescribing cascades, process maps have been identified as a practical way to unravel complex relationships and assist with identifying prescribing cascades in order to optimize prescribing. A process flow map (Figure 22-2) is a workflow diagram that shows the flow of clinical events. Its purpose is to provide insights into aspects of the patient’s care that may have gone wrong and areas where improvements can be made. These process maps have been used at the bedside and in the ambulatory setting to explore complex prescribing cascades and to improve health and well-being.

FIGURE 22-2. How to create a clinical process map of a prescribing cascade, and an example of a clinical process map investigating a prescribing cascade. (Modified with permission from Piggott KL, Mehta N, Wong CL, et al. Using a clinical process map to identify prescribing cascades in your patient. BMJ. 2020;368:m261.)

Appropriate prescribing is also a highly dynamic process that changes with time, incorporating considerations of age-related physiological changes (eg, changes in renal and hepatic function), disease-related factors, and shifts in the older individual’s goals of care. An important tension also exists between avoiding inappropriate medications (“errors of commission”) and avoiding

the underuse of potentially beneficial drugs (“errors of omission”). As a result of these many influences, appropriate prescribing for older adults represents a complex and ever-shifting balancing act for clinicians.

Polypharmacy may be necessary and appropriate in some patients to permit the optimal management of their multiple chronic conditions.

Underuse of beneficial therapy must be carefully balanced against inappropriate overprescribing. The tension between these two aspects of prescribing is complex. Interestingly, overprescribing of inappropriate medications and underprescribing of beneficial medications are correlated, with both simultaneously present in more than 40% of older adults in some studies.

Underuse of medications is conceptually defined as the absence of initiation of an effective treatment in an individual with a condition for which there exists one or more medications with a favorable benefit-to-risk ratio. Frail older adults are often underrepresented in pivotal clinical trials evaluating medications and the true benefit-to-risk ratio may be different from that observed in younger and healthier study participants. Thus, determinations of underuse require a careful assessment of whether randomized clinical trial results are truly generalizable to the older adult being cared for in real-world settings of care. Analyses focusing on older participants and post-marketing pharmacosurveillance studies can provide a more complete picture of the likely benefits and risks of medications that may not be initially apparent.

Attempts have been made to operationally define medication underuse in older adults. Analogous to the development of tools designed to define potentially inappropriate prescribing or “errors of commission”; there are now tools available to assist with the operational definition of underuse of potentially beneficial medications.

The START criteria represent an explicit tool to identify underuse of potentially beneficial medications. The START criteria include 34 evidence- based prescribing indications for older adults and also categorize medications according to organ system. The prevalence of potential prescription omissions, according to START criteria, was 23% among older

adults in primary care, from 42% to 66% in hospitalized older adults, and from 42% to 44% among nursing home residents.

Different approaches to profiling underuse of potentially beneficial medications have been applied. A common approach to characterizing underprescribing is to assess the use of medications that clinical practice guidelines suggest should be prescribed to treat or prevent a condition in the absence of contraindications. This approach has been used in a number of studies to demonstrate underuse of specific drug therapies in the care of patients with heart failure, myocardial infarction, osteoporotic fractures, atrial fibrillation, and depression. Unfortunately, most clinical guidelines do not incorporate considerations such as life expectancy and time needed to derive clinical benefit as legitimate justifications to forego prescribing a “beneficial” medication to a patient. In addition, several studies have emphasized that caution should be exercised when applying disease-specific clinical practice guidelines to older adults with multiple chronic diseases.

Incorporating an individual’s goals of care and preferences is critical to making optimal prescribing decisions relating to older patients. Holmes and colleagues have proposed a practical strategy whereby life expectancy, time to realization of treatment benefit, primary goals of care (eg, prevention, cure, or palliation), and validity of specific treatment targets (eg, blood pressure) are integrated to decide on appropriate treatments for older individuals with the aim of minimizing unwarranted polypharmacy.

Information about estimating remaining life expectancy in older adults can inform decision making around prescribing a new medication, as an understanding of the lag time until benefit is achieved for a specific medication under consideration. In individuals with advanced dementia for whom the primary goal is focused on quality of life, there may be opportunities to deprescribe medications that were previously considered essential (eg, lipid-lowering therapy with statins) to help reduce the overall pill burden, cost, and the potential for drug-drug interactions and ADEs.

An important example of striking the right balance is the case of antihypertensive treatment regimens in older adults. In 2015, a landmark trial

titled SPRINT evaluated the benefits of intensive versus standard blood pressure control and concluded that among patients at high risk of cardiovascular disease (eg, > 75 years), a systolic blood pressure target of less than 120 mmHg resulted in decreased death from any cause. However, applying this intensive target to all adults over the age of 75 without considering comorbidities, the risk of falls and frailty status may have unintended harmful results. Prescribers should be cognizant of the potential for increased harm from a systolic blood pressure target of less than 140 mmHg in the following patient groups: older than 80 years, moderate to severe frailty, cognitive impairment or functional limitations, history of orthostatic hypotension or labile blood pressure, syncope and falls.

Intensifying blood pressure medications in hospitalized older adults is particularly problematic and can lead to adverse outcomes such as syncope and falls. Maximizing the net benefit of blood pressure treatment in older patients requires applying the guidelines in an individualized manner while considering the setting, patient values and preferences, and level of comorbidity and frailty.

Long-term care residents include a disproportionate number of women, people of advanced age, and those with multiple chronic conditions including dementia. Medications are the most commonly used therapeutic intervention in the nursing home setting. Nearly half of all nursing home residents take nine or more medications every day, placing this group at particularly high risk for ADEs.

In long-term care homes, excess use of antipsychotic therapy for the management of the behavioral and psychological symptoms of dementia continues to be a focus of great concern. Atypical antipsychotic medications are among the drugs most frequently associated with adverse events in long- term care homes. While recent data suggest that use of antipsychotic therapy has declined in US nursing homes over recent years, nearly one in five long- stay nursing home residents continue to be prescribed antipsychotic medications. Further, there is substantial variation in the use of antipsychotic

therapy by geographic region and between nursing homes in the same region. A study of antipsychotic therapy in provincially regulated Canadian nursing homes found that antipsychotic prescribing rates were more than double in those with the highest rates of antipsychotic prescribing compared to those with the lowest rates of antipsychotic prescribing. Compared with individuals residing in nursing homes with the lowest mean antipsychotic prescribing rates, those residing in homes with the highest rates were three times more likely to be dispensed an antipsychotic therapy irrespective of their potential clinical indication. There is accumulating evidence that the benefit from atypical antipsychotics for the management of behavioral and psychological symptoms in Alzheimer-type dementia may be offset by the increased risk for ADEs. There is also evidence that antipsychotic use is associated with an increased risk of death with both conventional and atypical antipsychotic drug therapy in older adults with dementia-related behavioral disorders. Health Canada and the US Food and Drug Administration (FDA) have issued strong warnings about their use. Given these important safety concerns, the use of antipsychotic therapy should generally be reserved for situations where the benefit clearly outweighs the risk, such as in situations where the behavior poses a risk to the resident or others. Additionally, antipsychotic therapy should be frequently reassessed, with consideration for lower the dose or discontinuing the therapy altogether in favor of superior nonpharmacological approaches.

The occurrence of preventable ADEs is among the most serious concerns regarding suboptimal medication use in the nursing home setting. Few studies have systematically examined the incidence of ADEs in the nursing home population. In a study conducted in two academic long-term care homes in Ontario and Connecticut over a 9-month period, drug-related incidents were detected by computer-generated signals from a computerized physician order entry system, clinical pharmacist investigators, and periodic review of medical record.

In this study, residents using anticoagulants, atypical antipsychotics, diuretics, anti-infectives, and anticonvulsants were at greatest risk for ADEs. Psychoactive drugs (ie, antipsychotics, antidepressants, and sedatives/hypnotics), cardiovascular and anticoagulants were the most commonly implicated drug categories associated with the occurrence of

preventable ADEs (Table 22-3). Confusion, oversedation, delirium, and hemorrhagic events were the most commonly identified preventable ADEs. Errors resulting in preventable ADEs occurred most often at the stages of ordering and monitoring. Among the prescribing errors, the most common were wrong dose, wrong drug choice, and known drug interaction.

Dispensing and administration errors were less commonly identified. Independent risk factors for experiencing a preventable ADE included using medications in several drug categories, such as antipsychotic agents, anticoagulants, diuretics, and antiepileptics. Extrapolating from the results of this research, 1.9 million ADEs per year may occur among the 1.6 million US nursing home residents and more than 40% may be preventable. There are almost 86,000 fatal or life-threatening ADEs per year, of which 70% may be preventable. Drug-related morbidity and mortality is one of the most important areas to target in efforts to both improve the quality of medical care for older adults and reduce the costs of health care for this population.

TABLE 22-3 ¦ FREQUENCY OF ADVERSE DRUG EVENTS AND POTENTIAL ADVERSE DRUG EVENTS IN LONG-TERM CARE FACILITIES BY DRUG CLASSA

Failures in the design of systems of care are considered the most important contributor to the occurrence of medical errors, as well as the injuries that result from some of those errors. Enhanced surveillance and reporting systems for ADEs occurring in the nursing home setting are required as are continued educational efforts relating to the optimal use of

drug therapies in the frail older patient population. However, as Leape et al. concluded in regard to the occurrence of serious medication errors, “preventive efforts that focus solely on the individual provider or which rely on inspection alone have limited impact. Analysis and the correction of underlying systems faults is much more likely to result in enduring changes and significant error reduction.” Ordering and monitoring errors in the nursing home setting may be particularly amenable to prevention strategies that use systems-based approaches. The benefits of these approaches to error reduction have been reported in the hospital setting with computerized order entry. A computer-based decision aid reduced in-hospital inappropriate dosing of psychotropic medications for geriatric inpatients. Successes in the hospital setting pave the way for similar efforts in long-term care. For instance, clinical decision support at the time of medication ordering has been shown to improve the quality of prescribing to long-term care home residents with renal insufficiency.

Selecting the right medication and the right dose to prescribe for an older adult is difficult because so little evidence is available to guide choices. Decision making often has to draw on information obtained from study participants who are different from those encountered in real world settings, where patients often have several medical conditions and are taking more than one drug. The results of clinical trials of treatments for conditions commonly affecting older people often cannot be directly extrapolated to individual patients, as older adults, particularly women, frail persons and those with multiple illnesses, have often been excluded from participation in clinical trials. This poses challenges to the adoption of clinical practice guidelines developed to improve the quality of health care for many chronic conditions. A review of clinical practice guidelines for nine common chronic diseases promulgated by national and international medical organizations found that they did not modify or discuss the applicability of their recommendations for older patients with multiple comorbidities. Most did not comment on medication burden, short- and long-term goals, and the quality of the underlying scientific evidence, nor give guidance for incorporating patient preferences into treatment plans. Boyd and colleagues

have reported that if relevant guidelines were followed, a hypothetical 79- year-old patient with osteoporosis, osteoarthritis, type 2 diabetes mellitus, hypertension, and chronic obstructive pulmonary disease would be prescribed 12 medications. The doses of those drugs may be inappropriately high, particularly for older women who are commonly underrepresented in clinical trials. There are several ways in which the quality and availability of information about the use of drugs in older adults might be improved.

These include enhancing the inclusion of older adults in drug trials, and using observational studies and systematic reviews to provide information to guide clinical decision making.

In 1989, the US FDA published “Guidelines for the Study of Drugs Likely to be Used in the Elderly.” The guideline was intended to encourage routine and thorough evaluation in older populations of the effects of new drugs being proposed for federal approval so that physicians would have sufficient information to use such drugs properly. The guidelines state “there is no good basis for the exclusion of patients on the basis of advanced age alone, or because of the presence of any concomitant illness or medication, unless there is a reason to believe that the concomitant illness or medication will endanger the patient or lead to confusion in interpreting the results of the study.” It was not until 1993 the US National Institutes of Health (NIH) created guidelines for the inclusion of women and minority groups in the studies that they funded. Further, it was only in 2019 that the NIH Inclusion Across the Lifespan policy was put in place to address the underrepresentation of older adults in their studies. The concern is that when policies focus separately on sex and age, the intersection required to identify older women who are most at risk for drug-related adverse events will be missed. Drug trials should include study subjects that reflect the group that would eventually be prescribed the therapy, but this is often not what happens.

A case in point are trials in cardiovascular disease, which is overwhelmingly a disease of old age. A recent study of NIH-funded trials before and after the introduction of the new Inclusion Across the Lifespan policy showed that despite the implementation of new safeguards, older adults continue to be underrepresented where 30% of trials had explicit age limits and 70% excluded participants due to factors which disproportionally

impact older adults (functional status, cognitive impairment, or decreased life expectancy). Meanwhile, outcomes relevant to geriatric populations, such as measures of function, mobility, or quality of life, were usually lacking. Another study examining NIH-funded phase III clinical trials since the introduction of the policy found that 67% of studies reported mean or median ages that skewed younger than expected for the disease or condition of interest. As with the cardiovascular trials, older adults were often implicitly excluded based on polypharmacy/concomitant medication (37%) or cardiac issues (30%). Ongoing evaluation of enrollment by age group and reasons for exclusions will be critical to monitoring the success of the policy and improving the collection of evidence for drug therapies in older adults.

The underrepresentation of older individuals in clinical trials can be considered from a variety of perspectives. Even in the absence of explicit age limits or criteria that preclude eligibility based on clinical or functional grounds, older adults may be excluded. Often large numbers of older patients need to be screened to enroll just one eligible study participant, with an adverse impact on costs and the ability to meet study timelines. In addition, participation in a clinical trial by an older adult may never even be considered, relating to a confluence of factors, including bias, value judgments, and rationalization. The dynamics of the patient-physician relationship may confuse legitimate clinical concerns with subjective feelings regarding what is best for the older adult.

Pharmacoepidemiology uses the science of clinical epidemiology to measure patterns of medication use and outcomes in large populations.

Pharmacoepidemiology allows assessment of the safety and efficacy of medications in large populations, which are often more diverse than the participants in randomized trials, over long periods of time.

The advantages of pharmacoepidemiology over randomized controlled trials include (1) detection of adverse events that are too rare or too delayed to be detected in randomized trials; (2) assessment of efficacy over longer periods in a broader population; (3) correlation of medication use with outcomes that may not have been assessed in randomized trials; (4) assessment of safety

and efficacy of medications beyond the stringent monitoring of a randomized trial.

Pharmacoepidemiology is a particularly useful tool to assess medications in older adults. Older adults are often excluded from randomized trials, either on the basis of age alone, or because of comorbidities, co- medications, or functional impairment. Observational pharmacoepidemiologic studies can assess patterns of medication use, safety, and efficacy in frail individuals. It is particularly important to understand safety and efficacy over many years when deciding whether to continue or cease medications in older adults who have often been taking their medicines for decades. Many randomized trials only assess disease and mortality outcomes, and pharmacoepidemiologic studies can correlate medication exposure with functional and quality-of-life measures that may be more relevant to older adults. Pharmacoepidemiology assesses the effects of medications in the presence of medication management issues that occur in real clinical settings, for example, limited adherence and monitoring.

Pharmacoepidemiologic studies can be limited by confounding and bias. Interpretation of studies is limited by variable prescribing patterns, variable comorbidities, confounding by indication, severity and prognosis, and controlling for the time dependency of drug use. Studies that rely on large epidemiologic databases often contain very limited clinical information, including the exact indication for prescribing a given medication. There are several emerging approaches to manage confounders, including restricting study populations to more homogeneous groups, creating a propensity score to predict the probability of receiving a drug based on baseline covariates, and examining within-patient variability of drug exposure using crossover designs.

Age-based exclusions may also have important secondary effects on the participation of women in clinical trials. A number of studies have demonstrated a strong association between the average age of participants in a clinical trial and the enrollment of women, because women account for a substantially greater proportion of the older adult population than do men.

Many of the ongoing concerns regarding the enrollment of women in clinical trials are intimately related to the exclusion of older participants.

The underrepresentation of older women and lack of sex and age disaggregated data in clinical research are concerning. The case of zolpidem dosing is just one example where increased harms for women were not discovered until post-marketing surveillance. A growing body of research highlights the influence of sex on drug-related adverse events and other clinically relevant health outcomes. Sex and gender factors are still largely neglected in research, and this has become starkly evident in the case of COVID-19 related studies, where less than 5% of investigators had planned for sex disaggregated data analysis in their studies. In the case of SGLT-2 inhibitors for diabetes, current guidelines do not reflect the fact that these drugs appear to be less effective in reducing major adverse cardiac events in women compared to men. Funding agencies must set analysis guidelines for drug trials to report sex disaggregated adverse events and outcomes for all therapeutics including vaccines and devices. Understanding the sex and gender factors that influence efficacy and adverse events will help regulatory bodies and providers provide safe, evidence-based, and equitable care.

A prescription may be written but not dispensed, or dispensed but not taken regularly. A common barrier to appropriate medication use relates to financial considerations. The use of drug therapy has been shown to be directly related to coverage of drug costs. It is estimated that more than 40% of all Medicare enrollees in the United States had no coverage for outpatient drug expenditures prior to the implementation of the 2003 Medicare Modernization Act. In the United States, cost has been identified as an important reason that patients do not take medication that are prescribed by their health care provider. Specifically, among older adults and prior to the implementation of Medicare Part D, 13% of a national sample of 13,869 noninstitutionalized Medicare enrollees reported cost-related underuse of medications. Those in fair to poor health, with multiple comorbidities, and without coverage were most at risk.

Following the implementation of Medicare Part D, there were incremental improvements in medication affordability for older Americans. Recent concerns have been raised that these trends, especially for Medicare beneficiaries with multiple chronic conditions, have plateaued or even reversed, indicating that high drug costs remain a persistent barrier for this vulnerable population. Practical strategies available to optimize pre- and post-discharge medication management have been reviewed and can aid in improving outcomes in vulnerable older patients.

Limited manufacturing of low-dose formulations of drug therapy may make it more difficult or expensive for patients to take their prescribed drug therapy. Low-dose therapy is often recommended for older adults but may not be manufactured or available from publicly funded drug programs in the prescribed low dose. For example, there is considerable evidence supporting the efficacy and greater safety of low doses of thiazide diuretic therapy in the treatment of hypertension in the older patient population. The Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure Guidelines suggest starting antihypertensive therapy at low doses. Specifically, these guidelines suggest that therapy could be initiated with a thiazide diuretic. Low doses of thiazide diuretics often produce as large an antihypertensive effect as larger doses, with a reduced risk for metabolic abnormalities.

Women are more likely than men to require a lower dose of drug therapies. Despite this there are only a very few drug therapies used by women that are manufactured with a dose for women and another for men. Zolpidem, a widely used sleep aid, was on the market for more than 20 years before data became available showing that next morning drowsiness interfering with the ability to drive was greater in women than men. As a result, the dose for women is now half of the dose that is recommended for men.

Medication review is required on a regular basis to determine if the medications prescribed to an older adult are appropriate for them.

report mixed results. All studies have reported that medication review leads to recommendations for different types of changes, including elimination of drugs, increasing the number of drugs, therapeutic substitutions, or better dosing. There are few reported statistically significant changes in patient drug use and drug expenditures. Studies that involved direct contact between the consulting pharmacist and the patient appeared to be more effective than interventions aimed at recommending drug changes to the patient’s physician. One intervention study found that patients were resistant to reducing medications to recommended levels, particularly psychoactive drugs.

Medication reconciliation determines if the prescribed drugs are taken as they have been prescribed and intended. In the United States, the Joint Commission has required accredited facilities to implement a system of medication reconciliation to reduce medication errors at transitions of care. Medication reconciliation is defined as the process of identifying the most accurate list of all medications that the patient is taking, including name, dosage, frequency, and route, by comparing the medical record to an external list of medications obtained from a patient, hospital, or other provider (Table 22-4). Patients and responsible physicians, nurses, and pharmacists should be involved in the medication reconciliation process. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. Changes in medication (different dose, discontinued therapies, additional therapies), common during care transitions, are a frequent source of medication errors and confusion. ADEs attributed to medication changes occurred in 20% of patients on transfer from hospital to a nursing home, happening most commonly for patients on readmission to the nursing home. One study found that discharged patients understood the potential side effects of their medications less frequently than their attending physicians believed. One Canadian multisite study found that 25% of 325 older adults experienced an ADE after discharge home from the hospital; half of these events were considered preventable. Medication reconciliation systems and processes have successfully reduced medication errors in many health care organizations. Pharmacy technicians at one hospital reduced potential ADEs by 80% within 3 months by obtaining medication histories of patients scheduled for surgery.

TABLE 22-4 ¦ FIVE STEPS OF MEDICATION RECONCILIATION

In the United States, policy efforts to promote the use of new health care information technology serve to encourage medication reconciliation as patients transition from one setting of care (eg, hospital, ambulatory primary care, ambulatory specialty care, nursing home, home health, rehabilitation) to another or from one health care provider to another. For example, the Health Information Technology for Economic and Clinical Health (HITECH) Act and Meaningful Use criteria (stage 1) require that health professionals who receive a patient from another setting of care or provider of care should perform medication reconciliation.

Medication reconciliation has been recognized as a key component of patient safety, but there remains a lack of consensus and evidence about the most effective methods of implementing reconciliation. Reviews suggest that this lack of consensus stems in part from the low certainty of the evidence.

Targeting specific vulnerable patient populations for medication reconciliation may be more effective than widescale nontargeted reconciliation efforts.

Physicians should limit prescribing a new drug therapy to situations in which benefits clearly outweigh risks and to use drug therapy only after potentially safer alternatives have been attempted. For example, the use of NSAIDs to manage pain in older adults with osteoarthritis may be inappropriate because safer options are available. Epidemiologic and clinical studies have characterized the adverse consequences of NSAID use in older adults, particularly the association between NSAID use and gastrointestinal bleeds and renal impairment. Thus, alternative approaches should be considered before NSAIDs are prescribed for indications such as osteoarthritis.

Possible nonpharmacologic approaches, such as gentle exercise and weight reduction, may be beneficial alternatives to treatment with NSAIDs. When pharmacologic therapy is required, a drug therapy with a more favorable adverse event profile, such as acetaminophen, should be tried first.

Another example is the use of nonpharmacologic approaches to manage behavioral and psychological symptoms of dementia. Behavioral symptoms such as wandering and agitation are common and represent a major source of disability and caregiver distress. These symptoms frequently result in prescriptions for psychotropic medications such as antipsychotic drugs, but these drugs are on average only modestly effective and can provoke serious adverse effects. Thus, nonpharmacologic strategies are increasing emphasized to manage behavioral symptoms in dementia, and are usually recommended as first-line treatments. The evidence base has grown recently to support a wide variety of nonpharmacologic treatments for the behavioral and psychological symptoms of dementia. Examples of effective nonpharmacologic treatment strategies include caregiver education and support, training in problem solving, and targeted interventions directed at the underlying causes for specific behaviors (eg, introduction of structured nighttime routines to reduce sleep disturbances). Nonpharmacologic management can improve both patient and caregiver quality of life and can help to reduce the inappropriate use of potential harmful psychotropic medications such as antipsychotic drugs.

Deprescribing has been defined by Scott as the process of “identifying and discontinuing drugs in instances in which existing or potential harms outweigh existing or potential benefits within the context of an individual patient’s care goal, current level of functioning, life expectancy, values, and preferences.” Medication review and reconciliation may indicate the need for changes to currently prescribed drug therapies, especially if new evidence has emerged about the benefits and risks of these drug therapies.

These changes may include discontinuation of a therapy prescribed for an indication that no longer exists or reduction in dosage of a drug that the patient still needs to take.

Physicians are often reluctant to deprescribe, for example, reduce or stop medications, especially if they did not initiate the treatment and the patient seems to be tolerating the therapy. Sometimes, medications only expose the

patient to the risks for an adverse event with limited or no therapeutic benefit. The use of chronic digoxin therapy among older adults with normal systolic function is one such example. Use of digoxin therapy by older adults is not without risk. Renal impairment that progresses over time or dehydration associated with a gastrointestinal or respiratory illness or a urinary tract infection may predispose older adults to digoxin toxicity. Often, digoxin therapy has been prescribed for years for reasons that were not well- documented. In a small study of 23 nursing home residents with normal sinus rhythm, normal ejection fraction, and no clinical evidence of heart failure, digoxin was discontinued in 14 residents. One patient developed a decreased ejection fraction (from 60% to 50%) and digoxin therapy was restarted even though the patient remained clinically asymptomatic. At 2 months following the discontinuation of digoxin therapy, all patients with digoxin therapy discontinued remained clinically stable. These findings suggest that digoxin can be safely discontinued in select nursing home residents. Other investigators, however, have found that discontinuation of digoxin therapy in patients with impaired systolic function can have a detrimental effect.

inertia—whereby drugs continue to be prescribed in the absence of periodic review of net benefit—and therapeutic momentum, where more drugs are added in response to new but questionable indications, including unrecognized side effects arising from preexisting medications, potentially resulting in a prescribing cascade. Therapeutic inertia can also be avoided by periodically repeating the process of comprehensive medication review, with this process triggered in particular at times when the patient experiences an important health transition (eg, development of a new medical condition and/or changes in their preferences or overall goals of care).

The DRUGS guide to optimize medication safety for older adults was created by an international group of eight geriatricians from six countries. This guide outlines steps for prescribers to follow to optimize drug prescribing for older adults (Figure 22-3). These steps are DISCUSS goals of care, REVIEW medications, USE tools and frameworks to guide decision making, follow a GERIATRIC medicine approach, and STOP medications

where appropriate, all while integrating critical sex and gender considerations.

FIGURE 22-3. DRUGS guide to optimising medication safety for older adults. (Reproduced with permission from Rochon PA, Petrovic M, Cherubini A, et al. Polypharmacy, inappropriate prescribing, and deprescribing in older people: through a sex and gender lens. Lancet Healthy Longev. 2021;2[5]:E290–E300.)

DISCUSS goals of care and what matters most to the patie nt. It is essential to tailor the prescribing approach to the individual patient and emphasize the importance of taking primary goals of care (eg, prevention, cure, or palliation) into consideration, an approach described by Holmes and colleagues. Others

have also emphasized the importance of incorporating patient preferences and what represents meaningful health outcomes for the individual and their family. For example, the Canadian Geriatrics Society 5M model highlights “Matters Most” as one of the pillars to optimizing geriatric care. Taking into consideration the health goals and care preferences of the patient and their family is a critical component of comprehensive care. With the patient’s overall goals of care in mind, it becomes easier to balance potential tensions between clinical practice guideline recommendations and the inappropriate generation of problematic polypharmacy.

REVIEW medications. To conduct a medication review, the prescriber should ask the patient to bring all the bottles of pills, dosettes, and/or blister packs that they are using to their visit. For example, patients may not consider over- the-counter (OTC) products, ointments, vitamins, ophthalmic preparations, or herbal medicines to be drug therapies and thus, need to be specifically told to bring these therapies to the visit. In addition, patients should be instructed to keep a complete, accurate, and up-to-date medication list including over-the- counter medications and herbal preparations. A patient-generated list is particularly important as they are frequently prescribed medications from several physicians and patients may receive their medications from several pharmacies.

A periodic comprehensive review of the drug regimen that a patient is taking is an essential component of the medical care of an older adult; this process is referred to as medication reconciliation with the development of the best possible medication history, including OTC and herbal/nutraceutical products as detailed earlier. In addition to an accurate and complete medication list, details regarding the patient’s medical history and the clinical indications for each medication, sociodemographic information (ie, gender considerations) previous ADEs including drug sensitivities and allergies should also be obtained and documented.

Although there are an increasing number of effective medications for preventing or controlling a range of illnesses and for alleviating many symptoms, several studies show that adherence decreases, and adverse medication effects increase, with the complexity of the medication regimen. The goal should thus be to implement the simplest regimen that controls the patient’s symptoms and illnesses, and optimizes disease prevention. A medication grid, which displays each medication with dosage and frequency, has been found effective at facilitating the reduction in medication

complexity. Where appropriate, nonpharmacologic approaches should be considered as first-line treatment.

It is important to emphasize that prescribing is a dynamic and iterative process and thus, the determination of appropriate prescribing needs should be periodically repeated, especially when the patient experiences an important health transition. Assessment for changes to a patient’s medication regimen should be conducted as the patient’s health evolves and also as newer evidence emerges about the benefits and harms of existing drug therapies and the introduction of newer treatments.

USE tools and frameworks. When reviewing medications, it is important to utilize available tools and frameworks to help guide decision making. Well-known tools used to identify potentially inappropriate prescribing include the Beers Criteria and the STOPP criteria. To identify drugs with strong anticholinergic effects, consider consulting the Drug Burden Index and the Anticholinergic Risk Scale. Frameworks that can guide medication reviews are the prescribing cascade and the US National Action Plan for Adverse Drug Event Prevention, which provides helpful guidance to inform prescribing.

These tools do not consider sex and gender. It will be important for clinicians to consider how sex and gender may impact their prescribing.

GERIATRIC medicine approach. When considering medication change, one approach described by Steinman and Hanlon is to match the patient’s conditions to each of the medications. Through this process, areas where there is a mismatch can be identified. For example, situations where a drug is used with no indication, conditions that may benefit from a therapy where a therapy is not currently being offered, and drugs that are being given for an appropriate indication but where there is room for improvement (eg, dose adjustment or substitution with a drug therapy with a better risk-to-benefit profile). Further, the match between the medical condition and the medications should be directed not only by clinical guidelines but should also take into consideration the patient’s goals of care and sociodemographic/sociocultural factors.

STOP medications. In some cases, there will be a need to deprescribe drug therapy by reducing the dose or stopping the medication entirely. The CEASE deprescribing protocol outlined by Scott provides excellent guidance of the factors to evaluate when considering discontinuing or reducing the dose of a medication.

Many ADEs are dose related, so it is critical to prescribe the minimal dose required to obtain clinical benefit. A classic example of a dose-related adverse event is the association between use of long elimination half-life hypnotic-anxiolytics, antipsychotics, and tricyclic antidepressants and the development of hip fractures. A dose-related association has been found for each class of drug.

Another clinically important example of the benefit of reducing the dose involves the intensity of diabetes treatment. The doses of oral hypoglycemic agents and insulin therapy should not result in overly tight glycemic control, as there is little evidence that using medications to achieve tight glycemic control in older adults with type 2 diabetes is beneficial. Tight glycemic control has been consistently shown to produce higher rates of hypoglycemia in older adults. Realizing this point, the American Geriatrics Society (AGS) has recommended in the Choosing Wisely campaign (an initiative of the ABIM) that physicians should generally avoid using medications to achieve hemoglobin A1c less than 7.5% in most older adults. The AGS suggests hemoglobin A1c targets should reflect the individual older adult’s treatment goals, health status, and remaining life expectancy. The AGS suggests that reasonable glycemic targets would be 7% to 7.5% in healthy older adults with long life expectancy, 7.5% to 8% in those with moderate comorbidity and a life expectancy less than 10 years, and 8% to 9% in those with multiple comorbid conditions and a shorter life expectancy.

Optimizing use of drug therapy is a critical priority for older adults and involves achieving the balance between overuse (over prescribing of inappropriate therapy), underuse (under prescribing of beneficial therapy), and misuse (eg, inappropriate dose or duration of therapy). Sex, gender, age, and frailty considerations are important to inform optimal prescribing decisions for all older adults. There are additional considerations that are needed when making prescribing decisions for older adults living in long- term care settings or with limited life expectancy. Prescribing cascades should be avoided and managed by deprescribing when noticed. Particular attention should be given to using all drug therapies only when required and at the minimum effective dose. Practical approaches that integrate patient’s values and preferences should be followed to ensure that older adults are receiving optimal drug therapy.

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Piggott KL, Mehta N, Wong CL, Rochon PA. Using a clinical process map to identify prescribing cascades in your patient. BMJ. 2020;368:m261.

Rochon PA, Petrovic M, Cherubini A, et al. Polypharmacy, inappropriate prescribing, and deprescribing in older people: through a sex and gender lens. Lancet Healthy Longevity. 2021;2(5):E290–E300.

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In the United States there is an increasing prevalence of substance use (eg, alcohol, tobacco products, cannabis, illegal drugs, and nonmedical use of prescription drugs) among older adults. The combination of population aging and increasing use of substances has created a growing public health problem; rising numbers of older adults are at risk for and experiencing unhealthy use, including SUDs. This public health problem is serious because older adults are more susceptible to the harms of substance use due to age-associated biological changes, social factors, increases in comorbidity, and the use of medications that may interact with substances.

Therefore, it is critical to understand the age-related epidemiology, risk factors, unique vulnerabilities, and approaches to addressing and managing the spectrum of unhealthy substance use, including at-risk use and SUDs.

Unhealthy substance use is typically defined as use that increases the risk for health consequences (hazardous or at-risk use) or has already led to adverse health or social consequences (harmful use and SUDs). For alcohol, at-risk use is typically defined as the use of alcohol at more than low-risk levels. In the United States, a standard drink contains 14 g or about 0.6 fluid ounces of pure ethanol (12 oz of beer, 5 oz of table wine, 1.5 oz of distilled spirits, 86 proof). The National Institute on Alcohol Abuse and Alcoholism (NIAAA) previously recommended that adults age 65 or older who are healthy and do not take medications should not have more than three drinks on a given day or

seven drinks per week. This recommendation is now replaced by the US Department of Health and Human Services and US Department of Agriculture’s 2020–2025 Dietary Guidelines that recommend all adults limit alcohol use to two drinks or less in a day for men and one drink or less in a day for women, on days when alcohol is consumed. The guidelines also recommend that older adults avoid drinking alcohol entirely if planning to drive or operate machinery, take certain medications, have certain medical conditions, or are recovering from AUD or cannot control the amount they drink. While the amount of cannabis use considered at-risk among adults is not clear in light of increasing legalization, cannabis potency, social acceptability, and subsequent increasing use among adult populations, any use could be considered at-risk for older adults. The Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5) outlines criteria for diagnosing SUDs, which are medical illnesses causes by repeated misuse of a substance or substances. According to DSM-5, SUDs are characterized by clinically significant impairments in health and social function and impaired control over substance use (Table 23-1).

TABLE 23-1 ¦ DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS 5TH EDITION (DSM-5) CRITERIA FOR SUBSTANCE USE DISORDERS (SUD) WITH CONSIDERATION FOR OLDER ADULTS

Alcohol Alcohol continues to be the most commonly used substance among older adults in the United States. While generally, older adults reduce alcohol use as they age, alcohol use is increasing within this population in the past decade. Data from the National Survey on Drug Use and Health (NSDUH) estimate that the past-year use of alcohol increased among adults age 65 and older nationally from 52% in 2010 to 56% in 2019. For adults age 65 and older, the prevalence of binge drinking in the past 30 days (defined as five or more drinks on the same occasion for men and four or more for women) was estimated nationally in 2019 at 11%, with the prevalence of meeting DSM-5 criteria for AUD at 2%. However, the

prevalence of AUD may be underestimated as the DSM diagnostic criteria for AUD are not ideal for older adults (see Table 23-1).

Tobacco Tobacco is the second most commonly used substance among older adults and is used primarily via smoking cigarettes. While over the last decade, cigarette smoking rates have gone down in the general adult population, they have remained stable in older adults. Data from NSDUH show the past-year use of tobacco has remained stable over the past 10 years among adults age 65 and older, with the past-year prevalence estimated to be 13% in 2019.

Cannabis While cannabis is federally illegal and remains a Schedule I drug under federal law, there has been a marked increase in the number of states that have legalized cannabis for medical and recreational use. Reflecting the changing laws and attitudes regarding cannabis, data from NSDUH indicate past-year use of cannabis increased from a national prevalence of 0.3% among adults age 65 and older in 2007 to 5% in 2019 and is likely to rise further as more states legalize cannabis. With the overall increase in cannabis use, there has also been an increase in cannabis use among older adults who also use alcohol. In 2015, 2.9% of adults age 65 and older who use alcohol also used cannabis, while in 2018, this prevalence increased to 6.3%.

Othe r substances Data from the 2019 NSDUH reveal that the prevalence of other illegal drug use such as cocaine, methamphetamine, heroin, and hallucinogens remains low (< 1%) among older adults, but such use may be hazardous for older adults, especially among those with comorbid conditions. The prevalence of SUDs as defined by DSM-5 criteria also remains low among older adults, with a 2019 national prevalence of 0.5% for all SUDs, not including AUD. While SUDs and AUDs both have a low prevalence among older adults nationally in the general population, it is crucial to recognize that several subpopulations of older people experience SUDs at much higher rates. Due to long-standing discrimination and vulnerabilities, older criminal justice-involved adults, older adults experiencing homelessness, and older persons living with HIV have a higher prevalence of SUDs than national populations.

Non-medical use of prescription drugs Because of increases in comorbidities, older adults take more prescribed and over-the-counter medications than younger adults and are therefore at increased risk for harmful drug interactions and

misuse. Nonmedical or misuse is typically defined as use in a way a prescriber did not direct, including use without a prescription, taking the medication for longer or in higher amounts than intended, or taking the medication for reasons other than prescribed. Misuse of psychoactive prescription medications, including opioids, benzodiazepines, hypnotics, and stimulants, are of particular concern and may indicate undertreated symptoms. Among adults age 65 and older, the national prevalence of past- year prescription psychotherapeutic misuse was 2.1% in 2019, with prescription opioids being the most commonly misused with a prevalence of 1.6%. The prevalence of misuse is likely higher than these reported rates as older adults prescribed these psychoactive medications may not view any use, even if for longer or in higher amounts or for reasons other than intended, as being misuse. Further, older adults who misuse psychoactive medications are much more likely to rely on physician sources for the medications compared to younger adults.

Despite contraindications for older adults, benzodiazepines are disproportionately prescribed to older adults. The estimated prevalence of benzodiazepine use among older adults is 13%, with up to a third using them long term. Therefore, prescription drug misuse is complicated in older adults as it is affected by overprescription, misdiagnosis (ie, symptoms of misuse being mistaken for other conditions like depression and dementia), accidentally taking more a prescribed medication than intended, mixing up of medications (eg, not knowing what medication is prescribed for or combining prescription and nonprescription drugs and dietary supplements), and potentially inappropriate prescribing, rather than intentional misuse.

The data on risk factors for unhealthy substance use in later life are most robust for alcohol use. While it is reasonable to extrapolate factors related to unhealthy alcohol use among older adults to other substances, the unique characteristics that may contribute to substance use and SUDs for specific drugs other than alcohol are not as well studied (Table 23-2).

TABLE 23-2 ¦ FACTORS ASSOCIATED WITH UNHEALTHY SUBSTANCE USE AND SUBSTANCE USE DISORDERS

Demographic factors Several demographic characteristics are associated with unhealthy drinking among older adults. Male gender and Caucasian race are those most strongly associated with late-life drinking. It is important to note that unhealthy alcohol use has increased sharply among older women over the past decade. In addition, adults age 65 to 74 are more likely to engage in unhealthy alcohol use compared to adults age 75 and older. For other substances, female gender is consistently associated with misuse of

prescription benzodiazepines, while male gender is associated with tobacco and cannabis use among older adults.

Social factors Generally, divorce, separation from a spouse, or being single are associated with increased drinking in late life, particularly among men.

Affluence is associated with alcohol use. Within a retirement community, having a more active social life with friends and family may increase one’s risk of unhealthy drinking in later life. Having sustained or increased social interactions from midlife into older age, mainly postretirement, tends to increase alcohol use.

Late-life transitions and events may also increase an older adult’s vulnerability to unhealthy substance use. Loss in many forms is associated with unhealthy substance use among older adults. Loss can take the form of bereavement, living arrangement transitions, declining overall health, and loss of function. Caregiving for a chronically or terminally ill loved one may increase the stress and subsequent vulnerability to unhealthy substance use.

Preretirement job satisfaction, involuntary retirement, and workplace stress can negatively impact how the older adult copes with retirement and has been shown to increase alcohol use in general and drinking problems.

In general, as the population ages, hospitalizations, disabilities, and physical and mental comorbidities increase, as substance use decreases. Among older drinkers, heavy drinkers have worse physical and mental health compared to moderate drinkers. Further, in most observational studies among adults, including older adults, being a drinker is associated with having fewer comorbidities and overall better health. This association of alcohol use and better health is likely due to selection biases common in observational studies of alcohol use as people with illness tend to stop drinking. This is referred to as the “sick quitter” hypothesis. Because of this selection bias, a population of healthy older drinkers is compared to unhealthy older nondrinkers.

Though data are sparse, those who continue to use substances other than alcohol in older age (eg, tobacco, opioids, cannabis, and methamphetamine) are more likely to have physical and psychiatric comorbidities. Specific conditions that older adults commonly use psychoactive substances to treat include chronic pain and insomnia. Alcohol, benzodiazepines, and cannabis are used as sleep aids. Alcohol, cannabis, and opioids are also used to treat

chronic pain. Prior history of SUDs, cognitive impairment, an avoidance coping style, loneliness, and boredom are also risk factors for unhealthy substance use. Undertreated insomnia and anxiety symptoms are risk factors for prescription tranquilizer or sedative misuse among older adults. For prescription opioid misuse, the motive for misuse is overwhelmingly for pain relief. Loneliness is a risk factor for cannabis, alcohol, and prescription drug misuse among older adults.

Even with low amounts of substance use, there is potential for harm due to physiologic and biological aging (Table 23-3). However, the nature and severity of many health risks may vary by type, amount, and frequency of the substances used, medical and psychiatric comorbidities, medications used, and functional status. Our understanding of potential harms among older adults is strongest for alcohol and sedating medications (eg, opioids and benzodiazepines), and what we do know about the health impacts of other substances is primarily from data in younger age groups.

TABLE 23-3 ¦ UNIQUE VULNERABILITIES TO HARMS OF SUBSTANCE USE

Aging affects drug and alcohol metabolism and distribution in the body. The liver and kidneys’ ability to metabolize alcohol, other substances, and

medications decreases. Cognitive function also evolves, including changes in the dopaminergic, glutaminergic, and serotoninergic systems. Changes in brain structure and function (eg, diminished white matter and increased permeability of the blood-brain barrier) can increase sensitivity to the psychoactive effects of substances. Body composition also changes; lean body mass and total body water decrease while total body fat increases.

Because alcohol is water-soluble, older adults who drink a given amount of alcohol have a higher blood alcohol level compared to younger adults who drink the same amount. Drugs that are fat-soluble, such as benzodiazepines, have a longer duration of action in older adults compared to younger adults. Therefore, substances with long half-lives, such as diazepam, can be excessively sedating. All these factors result in older adults who consume a variety of substances having more significant impairment, lower tolerance, and less awareness of their impairment than younger adults. This contributes to an increased risk of harm including confusion or delirium, falls, intoxicated driving, injuries or accidents, impaired functioning, and an increased risk for substance use–related emergency visits, hospitalizations, and nursing home admissions.

Older adults are also vulnerable to the harms of substance use as even low levels of substances may exacerbate existing comorbidities (eg, alcohol worsens gout) and cause other conditions (eg, tobacco worsens chronic obstructive lung disease). Substances can worsen symptoms of insomnia (eg, alcohol, stimulants) and memory impairment (eg, benzodiazepines, cannabis). They can also interact with many medications, increase medication side effects, or lessen their efficacy. For example, alcohol and niacin can cause flushing and itching, alcohol and nitrates increase risk of hypotension, and opioids and other sedating medications can cause excessive sedation. These interactions are magnified when multiple substances are used. For example, concurrent use of alcohol and benzodiazepines increases further the risk for injury and cognitive impairment.

Other factors that increase risks for harm among older adults are the common practice of seeing multiple prescribers, each of whom may prescribe medications without full knowledge of other prescribed and over- the-counter medications, and nonmedication substances used by the older adult. Older adults may borrow medications from other household members, use medications for reasons other than intended, unintentionally take the wrong medication, take more than intended, and stockpile medications. Older

adults may not be aware that their use of the substance exceeds recommended limits or is risky when combined with other substances.

Addressing Unhealthy Substance Use and Substance Use Disorders Avoiding stigmatizing language In the United States, drug use and addiction treatment are heavily stigmatized. Stigma and stigmatizing language can

receiving the care they need. Earlier cohorts of older adults, those born before or during World War II and those who grew up during Prohibition and the Temperance Movement, are more likely to consider substance use as a moral failure. This group will need a particularly sensitive approach to substance use screening. The Baby Boomers, born between 1946 and 1964, grew up when substance use was more acceptable and may have more permissive attitudes about substance use. They also may be more willing to engage in substance use screening and assessment. Health care providers often address alcohol and drug use differently from other health risks, contributing to continued stigma. The American Society of Addiction Medicine, along with other national organizations, have published policy statements on terminology and advise against using potentially stigmatizing terms, including “abuse or abuser,” “user,” “addict,” “junkie,” or the terms “clean versus dirty.” Instead, language should place substance use in a health context and focus on the medical nature of SUDs and its treatment. The National Institute on Drug Abuse (NIDA) emphasizes that SUDs are a chronic brain disease, often with periods of recurrence, and a strong genetic component that can produce profound brain structure and function changes.

Thus, providers must talk with patients about substance use in the same way they discuss other chronic medical conditions such as cardiovascular disease or diabetes. Therefore, the discussion surrounding alcohol and other substance use should occur in the context of an older adult’s overall health with the goals of optimizing health, function, independence, and quality of life.

Unique issues Despite the increasing prevalence of substance use among older adults, this population is less likely to be screened for unhealthy substance use than younger adults. The US Preventive Services Task Force (USPSTF) recommends screening all persons age 18 and older for unhealthy alcohol,

tobacco, and drug use. The Substance Abuse and Mental Health Services Administration (SAMSHA) recommends screening all older persons at least annually. Screening for substance use faces many barriers, including lack of time, competing health issues, and the challenges of integrating screening into regular clinical care. Patients, their families, and providers may be uncomfortable discussing and reporting stigmatized behavior such as substance use, especially among older adults. Further, signs and symptoms of unhealthy substance use may be mistaken for manifestations of other chronic diseases (eg, weight loss, depression, insomnia, cognitive impairment). A common perception among older adults is that symptoms of unhealthy substance use are due to aging or other diseases and not to the substance itself. Regardless of its difficulties, universal screening helps identify patients at risk or who are currently engaging in unhealthy substance use behaviors.

Approaches to screening When assessing individuals of any age regarding substance use, it is vital to understand that stigma is a significant barrier for people with SUDs from seeking and receiving help. Therefore, as discussed earlier, it is imperative that the language used when discussing issues of substance use with patients is not stigmatizing. As part of overall health promotion, one can reduce stigma by asking questions about quantity and frequency of drinking, medications (prescription and over-the-counter), and other drugs, including various forms of cannabis and illegal drugs, in a nonconfrontational and supportive manner.

Diagnostic challenges for SUDs When screening older adults for unhealthy substance use, it is also important to recognize that specific physiologic, biological, and social factors unique to older adults may pose challenges in the accurate diagnosis of SUDs. Table 23-1 presents several DSM-5 criteria for SUDs and lists special considerations for older adults. Due to the physiologic and biological changes of aging that may increase the effects of substances, older adults generally experience a reduction of tolerance as they age—eliminating one of the hallmarks of DSM-5’s criteria for SUDs.

Additionally, changes in social and vocational roles, such as retirement or loss of peers, may mask problems related to substance use. Another challenge is the criterion of continued use despite persistent or recurrent problems may not apply to older adults who may mistake their problems related to substance use for normal aging. Therefore, given the diagnostic challenges, many older adults are “diagnostic orphans,” individuals who

qualify for only one diagnostic criterion for SUD and are therefore subthreshold.

Screening instruments Several screening instruments for unhealthy substance use are available for various substances (alcohol, tobacco, illegal drugs, and prescription drugs), but only a handful, focused on alcohol, were explicitly designed for and validated in older adults. The USPSTF and SAMSHA recommend the AUDIT-C and AUDIT for screening for unhealthy alcohol use. Interviewer-administered one-item and two-item screening tests for unhealthy alcohol and other drug use have been validated in the general population and may be a way to start asking about substance use. An alternative are self-administered screening tools, which may help patients feel more comfortable reporting stigmatized behavior. It is important to note that many of the available screening tools use higher unhealthy alcohol use thresholds than what is recommended for older adults.

The Alcohol Use Disorders Identification Test (AUDIT) and AUDIT-C The World Health Organization (WHO) developed the AUDIT as a screening tool to assess excessive drinking. The AUDIT has been used in a variety of settings and diverse populations, including older adults. The AUDIT contains 10 items that assess alcohol consumption, drinking behaviors, and alcohol-related problems in the past year. Scoring on the AUDIT ranges from 0 to 40, with each item assigned 0 to 4 points. The cut-off for a potential AUD beginning with a score of eight. However, studies have shown a lower score of five is more accurate in identifying older adults with potential unhealthy drinking.

The AUDIT-C is a shorter version of the AUDIT and consists of the first three questions of the AUDIT: How often do you have six or more drinks on one occasion? How often did you have a drink containing alcohol in the past year? How many drinks containing alcohol did you have on a typical day when you were drinking in the past year? A score of three or more is indicative of potential unhealthy drinking. These measures have high sensitivity and specificity in adult populations.

The Michigan Alcohol Screening Test-Ge riatric Ve rsion The Michigan Alcohol Screening Test-Geriatric Version (MAST-G) was the first instrument designed to identify drinking problems among older adults. The MAST-G has

24 yes/no questions with five or more positive responses indicating problematic alcohol use. The questions focus more on potential stressors and behaviors that are common among older adults. The MAST-G has high sensitivity (95%) and specificity (78%) and generally has strong psychometric properties. The Short MAST-G or SMAST is a 10-item version; two or more positive responses indicate potential unhealthy alcohol use.

The Comorbidity Alcohol Risk Evaluation Tool (CARET) The CARET is a more comprehensive screening and assessment instrument for unhealthy alcohol use developed for older adults that assesses risk based on alcohol use behaviors, health-related conditions, and symptoms that may be caused or worsened by alcohol (ie, liver disease, gout, hypertension, stomach pain, memory issues), medications that may interact with alcohol or whose efficacy may be diminished by alcohol (eg, pain and sedating medications), and risky behaviors (ie, drinking and driving). It is scored using an algorithm that considers alcohol amount with the other factors to indicate potentially unhealthy alcohol use. It has a sensitivity of 91% and sensitivity of 68% in identifying older unhealthy drinkers.

The CAGE and CAGE-AID The CAGE questionnaire is one of the most commonly used screening tools for unhealthy alcohol use. It has four questions, and scoring ranges from 0–4 with a cut-off of 1 as the suggested threshold to identify unhealthy drinking in older adults and women. It has been studied in older adults with a sensitivity of 86% and a specificity of 78% to detect lifetime AUDs. The limitations of the CAGE are that it does poorly in identifying binge drinkers and does not distinguish between lifetime versus current use. The CAGE-AID consists of the CAGE questions that have been altered by expanding the scope of the questions to include drug use but has not been studied in older adults.

NIDA Quick Screen V1.0 This interviewer-administered brief screener asks about past year use of alcohol, tobacco, prescription drugs (nonmedical use), and illegal drugs. If respondents answer more than never, the interviewer is directed to substance-specific follow-up questions or resources to continue screening and assessment.

Tobacco, Alcohol, Prescription Medication, and Othe r Substance Use (TAPS) tool The TAPS tool combines screening and brief assessment. It consists of four-item screening questions about past-year frequency of use for tobacco, alcohol,

illegal drugs, and nonmedical use of prescription drugs (similar to the NIDA Quick Screen), followed by a substance-specific assessment of risk level for individuals who screen positive. Scores on these questions generate a risk level per substance endorsed based on a range of possible scores per substance. The TAPS tool has the flexibility to be administered face-to-face or self-administered using a tablet computer. TAPS has been validated in a diverse population of adult primary care patients, but not specifically for older adults.

The Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) The ASSIST is another screening instrument developed by the WHO that screens for tobacco, alcohol, and illegal drug use. An interview is administered with eight questions that help assess the risk level and guide treatment decisions. The ASSIST, while widely used in research and clinical practice, has not yet been validated in older adults.

If screening indicates unhealthy substance use, then an assessment for a SUD should occur using the DSM-5 criteria (see Table 23-1). Also, to guide advice given for both those with and without SUDs, older adults should be questioned about the circumstances of their substance use (eg, when and with whom they use substances, why they use substances), their medical and psychiatric history, prior and current substance use history, medications, symptoms that may be caused or exacerbated by substances, symptoms that are often treated by substances (eg, chronic pain, insomnia, anxiety, depression, loneliness), social support, and functional status. These assessments should be complemented by a physical examination that includes a cognitive assessment and fall-risk assessment.

Interventions to reduce substance use may include psychosocial interventions or medications. Screening for substance use, brief intervention, and referral to treatment (the SBIRT model) have been promoted to facilitate getting people into treatment. Brief interventions can be performed in almost any clinical setting and by nearly any trained medical staff. They are an approach best used for unhealthy substance users who do not meet the criteria for a SUD. For those with a suspected SUD, referral to more extensive treatment

that includes more intensive psychosocial interventions and medical treatment may be warranted.

Brief interventions Brief interventions, which range from 15 minutes of brief advice to up to four 1-hour long sessions of psychotherapy, are usually conducted in person. Common counseling techniques used in SBIRT programs are borrowed from motivational interviewing (MI) and cognitive- behavioral therapy (CBT). Brief interventions provide the older adult with information about potential harms and consequences of substance use, enhance motivation to change, identify goals, and, where needed, refer to more intensive services. Many older patients are unaware of low-risk drinking limits or that substances may worsen existing chronic diseases, contribute to symptoms, or interact with medications. Brief interventions that focus on alcohol and prescription medication misuse are effective for older adults.

Brief advice by clinicians is recommended by NIAAA and NIDA when the initial screening of an older individual indicates they are engaging in unhealthy substance use. Similar recommendations are made by the USPSTF for tobacco users. Specifically, it is recommended that clinicians share the screening results and make clear recommendations. As an example, a provider might say: “Based on your responses to the screening questions, your current use is more than is medically safe.” It is essential to relate the advice about substance use to the context of a patient’s health and use nonjudgmental, non-stigmatizing language. This is an opportunity for providers to deliver a brief intervention that engages the patient in education about the substance, its potential health-related consequences, provides feedback and advice. It is also an opportunity to share how guidelines specifically relate to older adults and how substances may adversely impact other chronic diseases and function.

MI focuses on enhancing motivation and self-efficacy utilizing a shared decision-making approach. It can be implemented as part of a brief stand- alone intervention or a supplement to longer term or more intensive treatment

of SUDs. It is a patient-centered intervention that encourages a nonconfrontational, supportive approach to promote healthy changes by eliciting and exploring the person’s reasons for change. The focus is to reduce ambivalence to change. While older adults may have uniquely strong motivations related to their life stage to reduce unhealthy substance use, such as optimizing health and preserving function, such an intervention may be less influential on behavior than in younger counterparts. Substance use may be viewed as “one last pleasure,” reducing the urgency among both older adults and their families for potential change. Additionally, low self-efficacy is associated with fewer health promotion behaviors among older adults due to perceiving the consequences of aging as nonmodifiable. Therefore, MI may be more challenging to implement with older adults compared to younger adults.

CBT helps individuals identify and correct unhealthy behaviors by applying a range of skills (eg, coping strategies, exploring positive and negative consequences of continued substance use) that can be used to stop unhealthy substance use. Ways to make CBT more beneficial for older adults are encouraging them to take notes, implementing sessions at a slower pace, and summarizing and repeating information. Other counseling strategies include problem-solving therapy (PST), which identifies the person’s view of the problem, defines the problem, brainstorms possible solutions, reviews them, selects the best possible solution, uses the solution, and tracks and adjusts it as needed over time.

Referral to treatment for those with a suspected SUD Older adults identified as needing more treatment (eg, than brief interventions can deliver) should be referred for specialized SUD treatment focused on SUDs. Some studies suggest that older adults do better in specialized SUD treatment than do younger persons, especially those that have services are tailored to their age group. Due to various factors, including lower rates of SUDs, issues with diagnosis, screening, and stigma, there are many fewer older adults who seek treatment. The website, https://findtreatment.gov/, is useful to locate SUD treatment programs. It is important to develop a plan for seamless transitions between services and patient handoffs. During treatment, it is important to keep in touch with the older adult and the treatment program. Twelve-step recovery support groups such as Alcoholic Anonymous (A.A.) and Narcotics Anonymous (N.A.), typically in conjunction with other treatments for a SUD,

help maintain abstinence, improve psychosocial functioning, and improve self-efficacy.

Medications Medications can be used in conjunction with or without psychosocial interventions to treat SUDs. Despite the significant and robust evidence base for the benefit of several pharmacological treatments for SUDs, such treatments are severely underutilized, especially among older adults. Due to the higher risks for complications, older adults require inpatient or closely monitored specialty care for alcohol or benzodiazepine withdrawal or detoxification. However, as geriatric medicine providers care for patients across the clinical spectrum of care in various care settings, including long-term care, they should be comfortable initiating or maintaining medications for SUD treatment.

There are three FDA-approved medications for treating moderate to severe AUD: naltrexone, acamprosate, and disulfiram (Table 23-4). None of them have been studied in long-term randomized controlled trials (RCTs) of older populations, which limits understanding of their actual benefits and challenges to older persons.

TABLE 23-4 ¦ FDA-APPROVED MEDICATIONS TO TREAT ALCOHOL USE DISORDER (AUD) AND OPIOID USE DISORDER (OUD)

Naltrexone is the only medication for AUD that has been tested in short- term RCTs among older adults. It reduces craving and the pleasurable effects

of alcohol, is usually well tolerated by older adults, and can be started while a patient is still using alcohol. It is considered first-line therapy for many patients and can be safely given with medications for HIV; however, it is contraindicated in patients with acute hepatitis, liver failure, or patients taking prescribed opioid medications since it is an opioid antagonist and will precipitate opioid withdrawal. Naltrexone is given orally in daily dosing or a monthly injection.

Acamprosate reduces symptoms of protracted withdrawal from alcohol, such as sleep and mood problems. Like naltrexone, it can also reduce craving and the pleasurable effects of alcohol. In clinical trials in younger adults, it is most effective for patients after initial abstinence from alcohol. Acamprosate does require three times a day oral dosing and requires dose reduction for renal insufficiency, but can be used for patients with liver disease or patients needing opioid medications.

Disulfiram triggers an acute physical reaction to alcohol, including flushing, tachycardia, nausea, chest pain, dizziness, and changes in blood pressure. These adverse effects, when used with alcohol, are negatively reinforcing. Because these effects can be harmful to older people, disulfiram is generally not recommended for use in older adults and, if used, is done so only with great caution.

While studies focused on older adults with opioid use disorder are limited, a large body of evidence demonstrates that medications for opioid use disorder (MOUD) decrease mortality. MOUD is often improved when combined with psychosocial treatment (counseling, mutual help groups), but MOUD should be the first-line treatment for opioid use disorder rather than psychosocial treatment alone. The number of adults age 55 and older who are on MOUD sharply increased nationally over the past decade, and geriatric medicine providers will increasingly care for patients on MOUD.

Currently, there are three FDA-approved MOUD, including methadone (scheduled II), buprenorphine (scheduled III), and naltrexone (see Table 23- 4). Like medications for AUD, those for OUD have not been tested in long- term RCTs among older adults.

Methadone, a full opioid agonist, is highly regulated in the United States and dispensed through licensed opioid treatment programs. It can prevent opioid withdrawal symptoms and reduce drug cravings. Methadone

Buprenorphine is a partial opioid agonist. Like methadone, buprenorphine decreases opioid use and reduces all-cause mortality among people with OUD. Studies comparing the two medications suggest that methadone may be slightly more effective than buprenorphine for retaining patients in treatment. However, in the absence of studies focused on older adults, several factors suggest buprenorphine may be a safer choice for older adults initiating MOUD. The risk of overdose with buprenorphine is significantly lower than methadone since it is a partial opioid agonist with a lower potential risk for respiratory depression given its ceiling effect.

Buprenorphine also has a shorter half-life and is likely safer for patients with ventricular arrhythmias compared to methadone. No dose adjustment is needed for renal impairment or dialysis, and while hepatoxicity is rare, dose reduction may be required for severe hepatic impairment.

Naltrexone is a full opioid antagonist and will block any euphoric effect of opioids and does not cause physiologic dependence or withdrawal when stopped, unlike opioid agonists. However, initiating naltrexone requires that patients are not taking opioids as it can precipitate withdrawal if opioids are present. Naltrexone, especially the long-acting injectable form, has been found to be more effective than placebo for OUD; comparisons with methadone or buprenorphine are limited. As described above, naltrexone is usually well tolerated by older adults and can be used for patients with both AUD and OUD. However, it is contraindicated for patients who require prescribed opioids for pain.

Reversal of opioid overdose Naloxone does not treat OUD, but it can reverse potentially fatal opioid overdoses, and low-dose naloxone is safe and effective in older adults. Intranasal naloxone kits and overdose prevention education should be prescribed to patients at increased risk for overdose, such as those taking daily doses of 50 morphine milligram equivalents per day or more, or concurrently with a benzodiazepine. Those with chronic obstructive pulmonary disease, obstructive sleep apnea, other SUDs, and mental health disorders are at increased risk for opioid-related death.

Friends, family members, and caregivers may also receive prescriptions and training in naloxone use.

All smokers without contraindications should receive at least one of seven FDA-approved treatments for tobacco use disorder. Though none have been explicitly tested in older adults, in adult populations, varenicline is more efficacious than other treatments, and varenicline combined with nicotine replacement is the most effective therapy. Combining more than one type of nicotine replacement therapy (short-acting and long-acting) is more effective than a single treatment. Initiation of varenicline before smoking is stopped may increase quitting success rates.

After patients with unhealthy substance use receive intervention and/or referral to specialty treatment, it is essential to maintain support and monitor progress by regularly checking in with patients and asking about substance use. For those older adults who are not ready to make a change, it is important to continue to be supportive and make it clear you are prepared to help if and when they are ready to make a change. For those who are making change, it is important to support their progress. Return to use is common, just as exacerbations occur for other chronic diseases that require changes in behavior to manage like congestive heart failure or diabetes. The focus should be on using nonjudgmental language and assisting patients in re- engaging with interventions to address unhealthy use.

Substance use and SUDs continue to increase among older adults and may present challenges for clinicians managing patients with multiple chronic diseases. Understanding that substance use and its treatment are highly stigmatized mandates that geriatric medicine providers use patient-centered and nonstigmatizing language when talking to their older patients. Screening for substance use can be challenging for older adults, and providers must consider unique aspects of aging to detect unhealthy use. Older adults with unhealthy substance use and SUDs must be offered evidence-based treatment and regularly monitored to support them.

Broyles LM, Binswanger IA, Jenkins JA, et al. Confronting inadvertent stigma and pejorative language in addiction scholarship: a recognition and response. Subst Abus. 2014;35(3):217–221.

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Han BH, Moore AA, Ferris R, Palamar JJ. Binge drinking among older adults in the United States, 2015 to 2017. J Am Geriatr Soc.

Han BH, Moore AA, Sherman S, Keyes KM, Palamar JJ. Demographic trends of binge alcohol use and alcohol use disorders among older adults in the United States, 2005 to 2014. Drug Alcohol Depend.

Han BH, Palamar JJ. Trends in cannabis use among older adults in the United States, 2015 to 2018. JAMA Intern Med. 2020;180(4):609–611.

Jonas DE, Amick HR, Feltner C, et al. Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis. JAMA. 2014;311(18):1889–1900.

Kuerbis A. Substance use among older adults: an update on prevalence, etiology, assessment, and intervention. Gerontology. 2020;66(3):249– 258.

Kuerbis A, Sacco P, Blazer DG, Moore AA. Substance abuse among older adults. Clin Geriatr Med. 2014;30(3):629–654.

Lehrmann SW, Fingerhood M. Substance-use disorders in later life. N Engl J Med. 2018;379(24):2351–2360.

McNeely J, Wu LT, Subramaniam G, et al. Performance of the tobacco, alcohol, prescription medication, and other substance use (TAPS) tool for substance use screening in primary care patients. Ann Intern Med. 2016;165(10):690–699.

Qato DM, Manzoor BS, Lee TA. Drug-alcohol interactions in older US adults. J Am Geriatr Soc. 2015 63:2324–2331.

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Schepis TS, Wastila L, McCabe SE. Prescription tranquilizer/sedative misuse motives across the US population. J Addict Med.

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The National Center for Complementary and Integrative Health (NCCIH) defines complementary approaches as those that may have originated outside of conventional medicine. Integrative health care brings together both conventional and complementary approaches in a safe, coordinated way.

Integrative health emphasizes a holistic, patient-focused approach to health care and wellness. These practices encompass dietary, psychological, and physical approaches, often in multimodal systems. In the past, the NCCIH was known as the National Center for Complementary and Alternative Medicine (NCCAM), but there has been a movement toward integrating complementary therapies with conventional care rather than using them as an alternative, so the term “alternative” has been deemphasized.

Both integrative and geriatric medicine aim to maximize health across an individual’s life span, including those living with chronic conditions, disabilities, cognitive impairment, and/or frailty. In addition, both fields emphasize the importance of a larger biopsychosocial framework in the provision of clinical care. A common thread between integrative and geriatric medicine is the concept of whole person health. While medical specialization has resulted in the development of life-saving pharmaceuticals and procedures, this reductionist framework can overlook the rich interdependence of systems and factors contributing to whole person health. It is well recognized that social determinants of health and lifestyle behaviors can contribute to disease among multiple organ systems, such as cardiovascular disease and diabetes mellitus. However, there has been less

progress made in the development of effective interventions to catalyze recovery from chronic, multi-system diseases, nor strategies that promote resilience and prevent their occurrence. Integrative medicine, by incorporating multimodal conventional and complementary health approaches, is well-situated to maximize whole-person care with the goal of promoting and restoring resilience.

The 2018 American Geriatrics Society White Paper on Healthy Aging stated: “Promotion of a realistic, dynamic, multidimensional view of healthy aging is an important goal obtainable through traditional and innovative models of health promotion and prevention.” Integrative medicine, by incorporating nonpharmacologic, multimodal approaches, is poised to serve in both the promotion of healthy aging and prevention and management of geriatric syndromes (Figure 24-1). Furthermore, the inherent multimodal approach is well-suited to preventing and managing complex geriatric syndromes, which extend beyond single organ systems and a traditional disease-based approach.

FIGURE 24-1. Integrative geriatrics framework to promote healthy aging and prevent and manage geriatric syndromes.

For the purposes of this chapter, complementary and integrative modalities are grouped into four major categories (Figure 24-2):

approaches among US adults comes from the 2012 and 2017 National Health Interview Surveys (NHIS). Approximately 30% of adults age 65 and over reported use of any complementary health approach in 2012. Older adults tended to use complementary health approaches less often than those aged 18 to 44 or 45 to 64, but consistent increases in use have been observed over

time. In 2017, yoga was the most popular approach among all adults, but meditation use was more common among older adults as compared to yoga and chiropractic manipulation. In general, non-Hispanic White adults reported use of complementary health approaches more often than Hispanic and non-Hispanic Black adults.

Reasons for use of complementary health approaches are varied. US adults reported using these approaches most commonly for back and neck pain, joint pain or stiffness, colds, depression, and anxiety. Over half of adults believed complementary health approaches would help when combined with conventional medical approaches. Approximately half of patients who use complementary health approaches did not disclose this to clinicians involved in their care. Reasons for this include clinicians not asking about complementary and integrative health approaches and concerns about clinician knowledge regarding these approaches. Cost is another important factor in use of complementary health approaches, with many adults reporting high out-of-pocket expenditure. This has improved over time for certain modalities: in 2012 60% of adults who saw a chiropractor had some insurance coverage, versus 25% for acupuncture and 15% for massage therapy, but coverage was more likely to be partial than complete. Most recently in 2020, the Centers for Medicare and Medicaid Services finalized a decision to cover acupuncture for low back pain.

There are several ways clinicians can improve disclosure of complementary therapy use to better care for their patients. An important strategy is to incorporate elements of the integrative health history into the comprehensive geriatric assessment (CGA) including: illness representation, patients’ perceived sources of stress and support, complementary and integrative modality use and history, current health behaviors, and dietary supplement use in the medication history (Table 24-1).

TABLE 24-1 ¦ INCORPORATING AN INTEGRATIVE MEDICINE HISTORY INTO THE COMPREHENSIVE GERIATRIC ASSESSMENT (CGA)

Ms. S is an 81-year-old female with history of cerebrovascular accident (CVA) complicated by residual left-sided weakness, atrial fibrillation, heart failure (HF) with preserved ejection fraction, gout, lumbar spinal stenosis, mild cognitive impairment, falls, and depression who presents to the outpatient geriatrics consult clinic. Her goal is to live independently as long as possible. Since her stroke 1 year prior, she has struggled with her gait and ambulates with a rolling walker. She had one fall in the past 6 months and is afraid of falling. She is interested in integrative therapies she could use to improve her health and well-being.

Ms. S reports some fatigue but no other current symptoms. She lives alone in the community. Ms. S is independent with activities of daily living (ADLs), but requires some assistance for instrumental activities of daily living (IADLs) such as shopping, heavy housework, and driving given physical limitations. She hired a homemaker to assist with cleaning and shopping; she relies on her daughter for transportation. She denies loneliness

and reports receiving limited social support from her church group. Her medications include allopurinol, apixaban, atorvastatin, fluoxetine, furosemide, gabapentin, senna, and vitamin E. She drinks one glass of wine on holidays, but otherwise denies substance use. She completed the Timed Up and Go (TUG) test in 15 seconds (= 12 seconds suggests increased risk of falls). Gait examination revealed decreased gait speed with uneven stride length and step height, but a normal base and no bradykinesia. Cognitive testing was notable for Montreal Cognitive Assessment (MoCA) score of 24 out of 30. She scored a 7 on the Patient Health Questionnaire-9 (PHQ-9), consistent with mild depression. A frailty screen was consistent with mild frailty.

In addition to tools from conventional medicine, what approaches might you recommend in the clinical care of this patient? How would you make this decision?

According to the World Health Organization, the use of herbal and dietary supplements (HDS) in the United States has increased significantly over the past two decades. Older adults tend to be the highest consumers of HDS, with nearly 70% taking an HDS in the past 30 days. Studies consistently show that women use HDS more than men, and family households with greater wealth also use more.

The Dietary Supplement and Health Education Act (DSHEA) was passed in 1994; it defined a dietary supplement as a product (other than tobacco) that is intended to supplement the diet; that contains one or more dietary ingredients (including vitamins, minerals, herbs or other botanicals, amino acids, and other substances) or their constituents; is intended to be taken by mouth as a pill, capsule, tablet, or liquid; and is labeled on the front panel as being a dietary supplement. Under this law, supplements can be marketed without proof of safety or efficacy if no claim is made for their use in the diagnosis, treatment, cure, or prevention of disease. Manufacturers can, however, make “structure and function” claims that a product enhances a normal body function or state. For example, saw palmetto can be marketed to support urinary tract health but not to treat benign prostatic hyperplasia. In contrast to prescription medications, which must be proven safe, the US Food and Drug Administration (FDA) must first prove that an HDS is unsafe before a product is taken off the market. In 2006, DSHEA was updated so

that dietary supplement producers were responsible for reporting serious adverse events related to their products. In 2007, the FDA published current good manufacturing practice guidelines, including requirements for manufacturers to test products to ensure product quality, confirm the absence of some contaminants, verify accuracy of labeling, maintain minimum standards for manufacturing and packing, monitor adverse event reports, and make all records available for FDA inspection. However, these guidelines are nonbinding on the manufacturer. Since 2007, the FDA has increased inspections of HDS manufacturers and enforcement of regulations. In 2019, the FDA reported that they will be updating the regulation of HDS to continue to promote safety, quality, and efficacy.

When approaching the use of HDS in older adults, the clinician should carefully weigh the anticipated benefit of the dietary supplement with the risk of polypharmacy. Approximately half of prescription medication users also use dietary supplements on a regular basis. The number of drugs taken by a patient has been shown to be the single most important predictor of harm, and both drug-drug and drug-supplement interactions must be considered.

Therefore, an integrative approach in the older patient should incorporate an assessment of polypharmacy and the practice of deprescribing to prevent harm and maximize health and well-being. Table 24-2 includes resources for clinicians regarding HDS safety.

TABLE 24-2 ¦ INTEGRATIVE MEDICINE RESOURCES FOR THE GERIATRIC HEALTH PROFESSIONAL

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For a discussion of multivitamins, please refer to Chapters 30, Nutrition Disorders, Obesity, and Enteral/Parenteral Alimentation and Chapter 46, Pressure Injuries.

Vitamin D is a fat-soluble vitamin that has numerous roles in the body, including bone health, the maintenance of normal serum calcium and phosphate concentrations, reduction of inflammation, and others. Older adults are at risk of vitamin D deficiency because of increased time spent indoors, reduced synthesis in the skin, and inadequate dietary intake. There is evidence that vitamin D supplements increase bone mineral density and reduce fracture rates in institutionalized older adults. For further information about vitamin D status and falls, please refer to Chapter 43, Falls.

Studies of vitamin D supplements and muscle strength have had inconsistent results. There is mixed evidence regarding vitamin D supplements and cancer prevention. Vitamin D supplements do not appear to help prevent or treat mild depression, but there have not been any studies to date in older adults with vitamin D deficiency who are taking antidepressants. Observational studies have shown an association between vitamin D deficiency and poorer cognition, but it is not clear if there is cognitive benefit from vitamin D supplementation.

Magnesium is a mineral that is a cofactor in numerous enzyme systems in the body. Supplements are available in many forms, such as magnesium citrate, oxide, and chloride. Older adults are at risk for magnesium deficiency given lower dietary intake and reduced gut absorption with age. However, it is difficult to assess magnesium stores since serum magnesium levels do not necessarily correlate with intracellular or bone stores, which is where most magnesium is stored.

Low magnesium intake is strongly correlated with hypertension, but clinical intervention studies have not demonstrated a consistent benefit. Magnesium supplementation appears to be beneficial in the prevention of migraine. Though magnesium deficiency may be a risk factor for osteoporosis, it is not clear that magnesium supplementation is effective for the prevention and management of osteoporosis. There is some evidence that magnesium is effective for insomnia, stress, and constipation. For a more

complete discussion of magnesium for constipation, please refer to the Chapter 87, Constipation.

Eicosapentaenoic (EPA) and docosahexaenoic (DHA) acids are the two main omega-3 long-chain polyunsaturated fatty acids that have been extensively studied in the prevention and treatment of cardiovascular diseases. Dietary sources of EPA and DHA include fatty fish, such as salmon, anchovies, and sardines. Despite the large number of studies, the research has produced inconsistent results. The reasons for this are several, including differences in who is being treated, whether or not they are on statins, the formulation used (EPA+DHA or EPA alone), the dose or duration of treatment, the placebo arm (eg, olive oil versus mineral oil), and the end point measured. The recent Omega-3 Fatty Acids in Elderly Patients With Acute Myocardial Infarction (OMEMI) trial found no reduction in clinical events in older patients with recent acute myocardial infarction who were treated with 1.8 g EPA/DHA daily for 2 years. In addition, the VITAL trial found that older individuals treated with 840 mg omega-3 fatty acids did not experience a lower incidence of major cardiovascular events or cancer than those treated with placebo in a 5-year follow-up. Two recent meta-analyses and reviews found fish oil slightly reduces risk of cardiovascular disease mortality and events (myocardial infarction, angina, stroke, HF, peripheral arterial disease, sudden death, and nonscheduled cardiovascular surgical interventions) and reduces serum triglycerides. However, with higher doses of EPA+DHA, there may be a reduction in myocardial infarction and coronary heart disease events. Fish oil supplements are relatively low cost and have benign side effect profiles. In addition, given the low drug-drug interactions with other standard therapies used in primary and secondary cardiovascular disease prevention, it is prudent to consider the potential benefits of omega-3 (EPA/DHA) supplementation, especially using 1000 to 2000 mg/d dosages.

These levels are rarely obtained in most diets, even those including some routine fish consumption.

Meta-analyses suggest that fish oil may be helpful, although there is quite a bit of debate. There is variability between doses, ratios of EPA to DHA, and other study design issues. The most effective preparations appear to have at least 60% EPA relative to DHA. In older adult populations, a 2018 meta-

analysis found mixed findings in studies of fish oil for depression. It appears that doses greater than 1.5 g of EPA/DHA may have benefit. Current large- scale studies are underway and will hopefully inform future guidelines.

There is no convincing evidence for the efficacy of fish oil supplements in the treatment of mild to moderate Alzheimer dementia, as well as age-related macular degeneration.

Coenzyme Q10, also known as ubiquinone or CoQ10, is endogenously produced and found throughout the body. It functions as a critical cofactor in the production of adenosine triphosphate (ATP), and its reduced form, ubiquinol, acts as an antioxidant. The majority of CoQ10 is in mitochondria where it serves as a critical cofactor in the electron transport chain and thus ATP production. CoQ10 can also be obtained through the diet or as a dietary supplement. Primary dietary sources of CoQ10 include oily fish (such as salmon and tuna), organ meats (such as liver), and whole grains. Most individuals obtain sufficient amounts of CoQ10 through a balanced diet.

As a dietary supplement, it is most well-known for its role in managing statin-associated muscle symptoms. While statins affect cholesterol biosynthesis, they also decrease the biosynthesis of CoQ10. Decreased circulating levels of CoQ10 are hypothesized to cause mitochondrial dysfunction, resulting in muscle pain, weakness, cramps, and tiredness. A 2018 meta-analysis of 12 RCTs found that CoQ10 supplementation decreased statin-associated muscle symptoms. This finding was independent of administration doses of CoQ10 (100–600 mg/d) or CoQ10 supplementation time (30 days to 3 months). Future studies will need to determine both optimal dose as well as duration of treatment.

CoQ10 supplementation may be beneficial for patients with HF, as HF is believed to be a low energy, reduced functional state due to metabolic alterations that affect both skeletal and cardiac muscle. The 2014 Q- SYMBIO study was one of the largest prospective RCTs of CoQ10 in the management of HF. Patients with moderate to severe HF (with reduced ejection fraction) were randomly assigned to receive either CoQ10 100 mg three times daily or placebo, in addition to standard therapy. At 2 years, there were significant reductions in major adverse cardiac events (ie, death, hospitalization) in patients receiving CoQ10. It was safe and well-tolerated.

CoQ10 has been purported to be beneficial in the treatment and management of numerous other conditions. This includes hypertension, diabetes, obesity, migraines, Parkinson disease, and kidney disease. In general, the data are limited due to heterogeneity in dosage, duration, and trial design.

Gingko biloba The dried leaf of the ginkgo tree has been used medicinally for thousands of years. Multiple pharmacologically active compounds have been isolated, including flavonoids and terpene lactones, which increase the production of nitric oxide and activate certain central neurotransmitters, which may contribute to gingko’s beneficial effects on memory and cognition. EGb761, the formulation that has been studied most extensively, is standardized to contain 24% flavonoid glycosides and 6% terpene lactones; it is approved by the German Commission E for the treatment of cognitive impairment and intermittent claudication. This was supported by a 2018

meta-analysis of randomized controlled trials studying EGb761 in the treatment of dementia; this study found that 22- to 24-week treatment with a standardized 240 mg EGb761 dose may lead to improvements in behavioral and psychological symptoms of dementia, as well as significant decreases in caregiver distress. In addition, another 2018 review found that this standardized extract also may alleviate tinnitus and dizziness that are often seen as concomitant symptoms in patients with dementia. A 2020 updated review noted that while ginkgo biloba may be able to improve the cognitive function in patients suffering from mild dementia/cognitive decline when given for more than 24 weeks and at appropriate dosage (240 mg per day), there is very little data on the long-term administration. In summary, there are conflicting data on the effect of ginkgo on cognition; however, with the paucity of options in the treatment of mild cognitive decline, ginkgo may be considered an option.

There are theoretical concerns about a risk of increased bleeding because higher antiplatelet activating factor activity has been demonstrated in vitro.

Cases of increased bleeding in patients taking ginkgo have been reported, but establishing a causal relationship is challenging because many of these patients had other risk factors including age and medications such as aspirin, NSAIDs, or warfarin. Of note, there have been no reports of bleeding complications in clinical trials. Ginkgo should still be used cautiously in

patients with bleeding disorders or who are taking aspirin, NSAIDs, warfarin or other anticoagulants, or other botanicals that may increase the risk of bleeding. Allergic skin reactions, gastrointestinal disturbances, and headaches occur in less than 2% of patients.

Vitamin E Vitamin E is a family of eight different lipid-soluble substances, namely a-, ß-, ?-, and d-tocopherol, and -tocotrienol. Vitamin E acts as a chain-breaking antioxidant, terminating lipid peroxidation. a-Tocopherol is the main vitamin E form found in the human body. It has important roles, including diminishing the rate of oxidative stress—an important component in the pathogenesis of atherosclerosis and nonalcoholic fatty liver disease. Although studies have suggested possible cardiovascular disease benefits, meta-analyses have not substantiated the protective effects of vitamin E. Furthermore, some meta-analyses have suggested increase in all-cause mortality when high doses are used. One reason for this has been the various forms and blends of vitamin E that have been studied. For example, it has been suggested that ?-tocopherol exerts a much more potent antioxidant, anti- inflammatory, and cardioprotective effect than a-tocopherol, the one present in most formulations. In cancer populations, including bladder, prostate, colorectal, and lung cancer, the benefits are inconclusive. Most meta- analyses of individuals with these cancers have found no benefit with vitamin E supplementation. A recent finding from the Women’s Genome Health Study (WGHS, N = 23,294) in which participants received 10-years of alpha- tocopherol in a placebo-controlled trial reported a highly significant gene (COMT) by alpha-tocopherol interaction, such that alpha-tocopherol was beneficial for cancer prevention among rs4680 met-allele (28%), but not val- allele (23%) homozygotes. This and other studies suggest the full benefit of HDSs may not be understood until they are evaluated within a precision medicine framework. Studies of the a-tocopherol form of vitamin E in individuals with mild cognitive impairment found that it does not prevent progression to dementia, nor improve cognitive function in people with mild cognitive impairment or dementia due to Alzheimer disease. With the caveat that more research is needed, a 2017 Cochrane review concluded there is some evidence that it may slow functional decline in Alzheimer disease.

There appears to be a benefit of a-tocopherol supplementation in nonalcoholic fatty liver disease, in that it improves hepatic steatosis and hepatic inflammation; however, there are inconsistent findings in its ability to improve liver fibrosis. The 2018 practice guidelines of the American

Association of Liver Disease recommend 800 IU/d of a-tocopherol for the treatment of biopsy-proven, nondiabetic patients with nonalcoholic steatohepatitis.

Glucosamine and chondroitin are naturally occurring compounds in the body functioning as the principal substrates in the biosynthesis of proteoglycan.

They are believed to relieve joint pain and slow the rate of joint destruction and cartilage loss by serving as chondroprotective agents and disease- modifying osteoarthritis drugs. However, the biology of both compounds is poorly understood. Results have been conflicting in clinical trials. This is largely due to differences in study designs and populations of patients, investigator bias, or the use of different drug formulations (eg, glucosamine sulphate vs glucosamine hydrochloride). Despite it being a commonly used dietary supplement, the American College of Rheumatology and the Arthritis Foundation (ACR/AF) do not recommend the use of glucosamine, chondroitin, or a combination product in hand, hip, or knee osteoarthritis.

The one exception is chondroitin in the management of hand osteoarthritis, where the ACR/AF has provided a conditional recommendation. This is due to a single trial of chondroitin sulfate, which found improvements in pain in hand osteoarthritis with a daily dose of 800 mg. Glucosamine and chondroitin have been found to have low potential toxicity.

S-Adenosyl-L-Methionine (commonly known as SAM-e) is a naturally occurring molecule that owns a chemically reactive methyl group, responsible for several physiological transmethylation reactions. It is ubiquitously present in cells, where it is involved in many cellular functions and takes part in several metabolic pathways—including synthesis of proteoglycans for cartilage along with myelination and synthesis of endogenous anti-inflammatory, neurotrophic, and antioxidant molecules. In addition, it has potential epigenetic effects involving synthesis, repair, and recombination of DNA.

SAM-e has been marketed for the treatment of depression and for other medical conditions such as osteoarthritis, fibromyalgia, liver disease, and migraine headaches. In general, the data are limited in interpretation with reference to high-quality randomized controlled trials. With that being said,

there are encouraging results for SAM-e as a monotherapy or as an adjunctive therapy. Moreover, there appears to be clinical consensus that SAM-e may be useful in treatment-resistant depression, especially as an adjunctive therapy. Similarly, SAM-e has been shown to have promise in the treatment of osteoarthritis, with respect to function and pain management; data are sparse, and further studies are needed.

Recommended daily doses of SAM-e range from 200 mg to 1600 mg taken in divided doses, depending upon the condition for which it is being taken and its severity, and upon the route of administration. Most commonly, SAM-e is administered orally; it has a short half-life, undergoing first-pass effects and rapid metabolism. Oral doses of SAM-e at 1600 mg/d are significantly bioavailable and nontoxic. Because SAM-e is best absorbed on an empty stomach, it should be administered 30 to 60 minutes before meals or 2 hours after meals. One reported but uncommon adverse effect of SAM-e is that it may induce mania in some cases. However, this should be interpreted with caution as individuals may be misdiagnosed with major depressive disorder, when they in fact have bipolar disorder.

Melatonin Melatonin is a lipophilic hormone that is an important regulator of circadian and seasonal rhythms. In humans, its primary physiological function is to control sleep-wake cycles and reinforce sleep behavior. Endogenous melatonin is produced by the pineal gland and regulated tightly by visual light cues in the hypothalamic suprachiasmatic nucleus. Production is inhibited during the day and disinhibited at night. In a healthy, normal individual, serum levels start to rise in the evening hours, reaching peak concentration around 2 to 4 am, after which levels decline again until reaching low daytime levels.

Melatonin levels decline with age due to altered hormone regulation and secretion, changes in renal and hepatic clearance, and other neuroanatomical degeneration. The lower peak levels of endogenous serum melatonin may be due to decreased pineal gland melatonin synthesis or pineal gland calcification. Endogenous melatonin synthesis may be further reduced by drugs (eg, benzodiazepines, NSAIDs, and calcium channel blockers). Mean levels of excretion have been shown to be particularly low in multiple, chronic disease states, so that older adults with chronic comorbidities might be especially vulnerable to inadequate melatonin levels and impaired sleep.

Studies suggest older adults are prone to disorders related to an altered circadian rhythm, including disorders of cognitive function, delirium, and sleep.

Exogeneous melatonin has been studied in various primary and secondary sleep disorders. It has been shown to induce phase shifts in the circadian pacemaker, synchronizing the sleep–wake cycle and restoring the circadian secretion pattern to normalize levels of melatonin. When administered acutely, it reduces core body temperature and lowers alertness, encouraging sleep propensity. Melatonin may have potential in treating disorders of sleep initiation, sleep maintenance, as well as circadian phase disturbance. In a recent meta-analysis of 12 randomized controlled trials the most convincing evidence was in reducing sleep-onset latency in primary insomnia, delayed sleep-phase syndrome, and regulating the sleep-wake patterns in blind patients compared with placebo. Much of the literature includes patients

aged 55 to 80. Ramelteon is a selective melatonin receptor agonist used in the treatment of insomnia. Studies show that ramelteon is effective in improving sleep latency, sleep efficiency, and subjective total sleep time for individuals with insomnia.

Dose, formula (extended release or fast acting), and timing of administration appear to be important, although not well-studied. There may be decreased effectiveness in patients with neurological deterioration or comorbid clinical disorders such as Alzheimer disease. Other studies report efficacy of melatonin in improving sleep quality in older adults with underlying neurodegenerative disorders. Two studies investigated the treatment of primary insomnia of older people (aged 55+) with melatonin (2 mg 1–2 hours before bedtime orally) and concluded long-term use of melatonin (for 13–24 weeks) is well-tolerated. Initial recommended starting doses of melatonin in older adults are 0.3 to 2 mg of immediate-release formulation melatonin, taken 1 hour before bedtime to best mimic the normal physiological circadian rhythm of melatonin and to avoid prolonged, supra- physiological blood levels; a maximum dose is 9 to 10 mg. Little evidence is available regarding the potential adverse effects of long-term melatonin use. Uncommon side effects potentially include headaches, dizziness, vomiting, and nausea.

Vale rian Historically, the therapeutic use of valerian is thought to date back to classical antiquity and the herb is touted as an anxiolytic and sleep aid. It was described by Hippocrates and prescribed by Galen in the second century

for insomnia. While there are over 200 valerian species worldwide, Valeriana officinalis L. is the most well-known in Europe and North America. Valerian preparations are available in aqueous or dry hydroalcoholic extracts, or as whole or communitive herbal roots and stems.

Potential mechanisms and sites of action include modulation of GABA receptors and increasing the amount of GABA available in the synaptic cleft. Other sites of action include adenosine A1 receptor activation and serotonin (5-HT5a) receptor signaling. The active ingredient of valerian is not agreed upon, and different constituents including volatile oils like valerenic acid (giving a characteristically unpleasant odor), sesquiterpenes, or valepotriates have been used to standardize valerian extracts. Combination herb preparations have been studied such as valerian-Humulus lupulus (hops), valerian-Melissa officinalis (lemon balm), and valerian-Passiflora incarnata (passion flower).

Several reviews and meta-analyses have been published with inconsistent results and criticism regarding methodological quality. Most recently in 2020, a systematic review of 60 studies of valerian for sleep problems and associated disorders was conducted, with a subgroup meta- analysis on subjective sleep quality (10 randomized controlled trials). This analysis concluded that valerian could be a safe and effective herb to promote sleep and associated disorders. However, inconsistent outcomes may be due to variable quality of herbal extracts and that more reliable effects might be expected from the whole root/rhizome. The safety profile of valerian is good, although some note caution in severe liver disease.

Importantly, valerian requires use for several weeks for effect. In contrast to prescription sedative hypnotics, valerian does not cause psychomotor retardation or impair cognitive performance and is non-habit forming with no reported withdrawal symptoms on discontinuation. A common dose is 300 to 900 mg of standardized extract (0.8% valerenic acid) or 2 to 3 g dried root taken as a tea 30 minutes to 2 hours before bedtime.

Black cohosh (Cimicifuga racemosa or Actaea racemosa), also known as bugbane, black snakeroot, or rattleweed, is a perennial plant from the buttercup family native to Canada and eastern US with a characteristic dark- colored rhizome. The rhizome extracts were traditionally used by Native Americans to treat multiple ailments including menstrual irregularity. Over

the past 2 decades, there has been steady interest in black cohosh for the treatment of menopausal symptoms.

The rhizome of black cohosh contains several potential, biologically active constituents (including the triterpene glycosides actein and cimicifugoside, as well as fatty acids, resins, caffeic acids, isoferulic acids, and isoflavones). Black cohosh was originally thought to be a phytoestrogen with its isoflavone component exerting estrogenic effects selectively on the LH receptor; however, recent studies have not consistently demonstrated this. Instead, central neuromodulation through the triterpene glycosides may be the mechanism of action, including dopaminergic effects that oppose prolactin (possibly affecting libido and bone metabolism), serotonergic effects (much like SSRIs widening the thermoregulatory zone for vasomotor symptoms and mood), and GABAergic effects.

While popular among women seeking nonhormonal options, the literature has been inconsistent. A Cochrane review in 2012 reviewed 16 RCTS of peri-/postmenopausal women using oral mono preparations of black cohosh at a median daily dose of 40 mg for a mean duration of 23 weeks concluded that there was insufficient high-quality evidence to recommend black cohosh in improving frequency or intensity of vasomotor hot flashes, vulvovaginal symptoms, or overall menopause symptoms score (including insomnia, headache, paresthesia, and anxiety). Since then, higher-quality studies have reported improvements in composite menopausal symptoms with black cohosh over placebo. There is significant heterogeneity in studies with regard to herb preparation, but many have standardized to 27-deoxyactein

(triterpene glycoside). The most studied commercial product is Remifemin® (contains 1 mg of 27-deoxyactein in one 20-mg tablet, to be taken 1–2 times daily).

The most commonly reported side effects are mild and transient gastrointestinal upset and rashes. Most studies have examined black cohosh use for 6 months or less, so long-term safety is not known. Due to theoretical estrogenic effects, caution should be used in any patient (eg, with history of breast cancer) for which estrogen therapy would be contraindicated. There has also been a concern raised regarding hepatotoxicity; however, there is little evidence to support an adverse effect on liver function.

Saw palmetto (Serenoa repens), from the berries of the American dwarf palm tree, is used for symptomatic benign prostatic hypertrophy. Available in multiple formulations including liquid extracts, tablets, capsules, and tea, the active components of palmetto extracts are not well understood but may include phytosterols, volatile oils, and free fatty acids. Purported mechanisms of action include weak inhibition of 5-alpha-reductase and the conversion of testosterone to dihydrotestosterone (DHT), inhibition of DHT binding in prostatic cells, anti-inflammatory effects, and inhibition of fibroblast and epithelial growth factors and induction of apoptosis.

Many earlier, smaller studies showed benefit of saw palmetto for mild to moderate lower urinary tract symptoms such as urinary frequency, nocturia, and dysuria as compared to placebo. Some studies suggested similar effects to finasteride or tamsulosin. Studies were unclear regarding an effect on urinary flow rate, but there is likely no effect of saw palmetto on prostate size or serum prostate specific antigen. The literature overall has been mixed. A 2011 multicenter RCT evaluated escalating doses beyond the standard dose (320 mg per day) up to 960 mg per day did not find that saw palmetto extract was better than placebo in ameliorating lower urinary tract symptoms of BPH. There was, however, also no difference in adverse effects suggesting overall safety. A 2012 Cochrane Review of 32 RCTs also concluded there was no difference between saw palmetto and placebo for BPH symptoms. Most recently, however, a 2018 meta-analysis which evaluated a particular European product of saw palmetto (hexanic extract

Permixon®) at the standard dose (320 mg per day) concluded that saw palmetto reduced nocturia and improved flow rate compared with placebo with a similar efficacy to tamsulosin and short-term 5-alpha reductase inhibitors in relieving lower urinary tract symptoms. Other studies have suggested that the efficacy of saw palmetto is enhanced with selenium and lycopene (a common commercial formulation) or may be useful as an adjunct to conventional medication and safe to use in combination.

The usual dosing is 160 mg twice a day with an allowance of 8 weeks therapy to evaluate effects. Side effects are uncommon and mild and may include dizziness, headache, nausea, vomiting, constipation, and diarrhea. Rare case reports of liver enzyme elevations have occurred resembling viral hepatitis with resolution within 1 to 3 months.

Mind-body practices encompass a diversity of interventions including movement-based practices (eg, tai chi, yoga, contemplative dance, Pilates, Feldenkrais) and less physically oriented practices such as seated meditation. The multimodal nature of these practices, and especially movement-based ones, which coordinate motor, cognitive, and breath training, reflects, their inherent integrative nature, and may explain their effectiveness in treating complex geriatric syndromes such as falls, chronic pain, cognitive decline, and affective disorders, which often involve multiple physiological systems. Here we highlight three of the most evidence-based mind body practices—yoga, tai chi, and meditation—with a focus on application to geriatric conditions.

Yoga is a multicomponent mind-body practice that incorporates physical postures, breath regulation, relaxation practices, and meditative techniques. Yoga has increased in popularity among US adults in recent years, from 9.5% reporting practice in 2012 to 14.3% in 2017. Most of this group were adults age 18 to 44, but interest and practice among older adults are expected to grow given baby boomers’ increased knowledge, acceptance, and access to mind-body practices.

Yoga practice seems to positively impact aging on multiple levels, from cellular stress to improvements in overall physical and mental health. Some small studies have suggested that yogic meditative practice may reduce telomerase activity in dementia care partners. Yoga practices are thought to reduce inflammation by downregulating the sympathetic nervous system response and hypothalamic-pituitary adrenal axis, thereby decreasing cytokine release. There have been several studies of the impact of yoga on cardiovascular function, suggesting improved heart rate variability, improved baroreflex responsiveness, and slowing of age-related changes in cardiovascular function. In addition, yoga may increase respiratory muscle strength. However, data are incomplete and variable in these areas.

Beyond the cellular and organ systems levels, yoga positively impacts multiple aspects of physical function in older adults. There are several randomized controlled trials demonstrating improvements in measures such as the timed up and go test, gait speed, chair stand test, 6-minute walk test, functional reach, tests of standing balance, range of motion, flexibility, and muscle strength. These trials were conducted in a variety of populations,

including the community, assisted-living facilities, and nursing homes. Interventions consisted of a variety of styles of yoga generally taught one to three times per week over 8 to 24 weeks. There are a few studies that showed improvements in higher level functional outcomes, such as ADLs or the ability to carry heavier objects. In one study yoga practice reduced the number of falls, but this was only seen in within-group analysis and was not significant in the yoga group as compared to an exercise control. In multiple studies yoga practices seem to improve fear of falling.

In terms of cognition, yoga likely has a positive impact, though the evidence is less robust than other areas. In a systematic review and meta- analysis of 12 studies including 912 older adults, about 70% of whom had preexisting cognitive impairment, yoga was beneficial for memory, executive function, attention, and processing speed. Neuroimaging of long-term versus naïve yoga practitioners has shown thicker gray matter in brains of long-term practitioners, including the hippocampus and those associated with attention, interoception, and sensory processing.

Yoga improves mood and quality of life in older adult populations. There are many randomized controlled trials demonstrating reduced depression and anxiety in older adults after a yoga intervention, and also many that demonstrate benefit for fatigue, quality of life, stress, and emotional well- being. Yoga interventions seem to improve social support, with at least one study demonstrating reduced loneliness.

There is consistent evidence to support the use of yoga for chronic low back pain—a 2017 Cochrane review found low- to moderate-certainty evidence that yoga resulted in small to moderate improvements in back- related function at 3 and 6 months. Many studies also suggest benefit for low back pain in addition to function. The American College of Physicians issued clinical practice guidelines in 2017 recommending yoga as one of many nonpharmacologic treatments to utilize as an initial approach in chronic low back pain (strong recommendation; low-quality evidence).

Adverse effects have been reported from yoga practice, though high- quality data are limited. In one study of approximately 2500 yoga class attendees with a mean age of 58 years, 27% of attendees reported an adverse event. These were mostly muscle and joint pain, followed by dizziness.

People over age 70 reported fewer adverse events, but orthostasis was more common in this group as compared to younger participants. There have been case reports of vertebral compression fracture, particularly in postures with

flexion or forward folding. There are some postures that should be avoided in certain medical conditions, such as inversions in participants with hypertension or glaucoma.

Clinicians who work with older adults should be aware of some basics of the yoga profession when referring patients. There are many styles and schools of yoga; all typically include an initial focus on physical posture (asana), breath control (pranayama), and sensory withdrawal (pratyhara), then moving to incorporate principles of ethics (yamas and niyamas) and meditation (dharana, dhyana, samadhi). Commonly utilized approaches for older adult populations, with focus on alignment and slower movements, include Iyengar yoga, chair yoga, and restorative yoga. However, most yoga styles can be suitably adapted for the needs of older adults under the guidance of an experienced teacher or therapist.

The majority of yoga teachers have a minimum of 200 hours of yoga teacher training and are typically certified by the Yoga Alliance. However, there is a large range of experience, with some teachers conducting classes right out of training and others having apprenticed with another teacher for many years. Yoga teachers may have additional expertise with specific populations, such as pregnant women or older adults. Yoga therapists are trained yoga teachers with a minimum of 800 additional hours of yoga therapy school through the International Association of Yoga Therapists.

They are trained to work with people with medical conditions in a safe and effective way. A yoga therapy prescription typically looks more like a physical or occupational therapy referral. Older adults who are experiencing more medical complexity and/or geriatric syndromes may benefit from one- on-one work with a trained yoga therapist rather than engaging in a general yoga class conducted by a yoga teacher. Physical and occupational therapists are often knowledgeable about yoga resources in the area and can help guide the patient and clinician in selecting an appropriate path for referral.

Tai chi is a multimodal mind-body exercise that originated in Asia, and is growing in popularity in the West, especially among older adults. Data from the 2012 and 2017 NHIS report prevalence of tai chi practice in the United States in the general population at less than 5%, substantially lower than yoga. However, it is thought that these numbers under-report growing use among older adults. Originally developed as a martial art, tai chi integrates

training in balance, flexibility, and neuromuscular coordination with multiple cognitive components including heightened body awareness, focused attention, imagery, multi-tasking, and goal-oriented training. This may underlie its benefits to balance, cognition, gait health, and chronic pain, as compared to conventional unimodal exercise. High-quality meta-analyses support that tai chi reduces falls by 20% to 45%, and a Cochrane review concludes it is among the best available exercise options for fall prevention in ambulatory older adults. A recent study reported that a 24-week program of twice a week group tai chi led to a 58% reduction in falls among those at high risk for falls, as compared to a stretching exercise control. There is also sound evidence that tai chi can effectively reduce falls in people with Parkinson disease. Experimental research supports that tai chi reduces falls by positively impacting multiple fall-related risk factors including: reduced lower extremity strength and flexibility, reduced proprioception and postural awareness, poor neuromuscular coordination, impaired executive function, and fear of falling.

In addition to fall prevention, a growing body of evidence supports benefits of tai chi for a range of cardiopulmonary and metabolic issues including chronic HF, hypertension, hyperlipidemia, and COPD. Mixed evidence suggests tai chi training may reduce the risk of stroke. Meta- analyses also support potential cognitive benefits, including improved executive and global cognitive function in older adults that are cognitively intact as well as those with mild cognitive impairment. Evidence for pain conditions including knee osteoarthritis and chronic neck and back pain is also promising, and recent studies have begun to specifically evaluate the benefits of tai chi for chronic and multisite pain conditions specific to older and frail adults.

Tai chi is a safe and adaptable exercise, including for frail older adults. A 2014 systematic review including 153 RCTs concluded tai chi is unlikely to result in serious AEs, but it may be associated with minor musculoskeletal aches and pains. However, poor and inconsistent reporting of AEs limits the conclusions that can be drawn regarding the safety of tai chi. A 2019 review (256 RCTs) with an embedded meta-analysis (24 RCTs) also reported higher levels of minor AEs typical of any exercise program. Subgroup analyses in HF patients reported significantly more serious AEs for inactive control interventions compared with tai chi.

Community-based tai chi programs for fall prevention have been shown to be scalable, effectively implementable, and cost-effective. The majority of successful programs have included group based classes that meet 2 times per week over a period of 3 to 6 months. There are no national standards for tai chi instructor certification, and programs can vary considerably. Similar to yoga, there are many styles and forms of tai chi available. However, they all share common principles and typically include core elements of body awareness and mindful movement. A common approach for older adults is Yang style tai chi, although most programs can be adapted for older adults who are deconditioned or have other physical limitations. Practical considerations when looking for a class include: experience of instructors, program focus (health vs martial applications), and accessibility. For individuals with significant health concerns, choosing teachers with experience teaching in a health care setting or formal training (eg, physical therapists, nurses, physicians) is suggested. Observing a single class and talking with others already enrolled in any given program before formally enrolling is advisable.

Tai chi has reportedly been associated with improved exercise self- efficacy. In combination with its safety and adaptability to many conditions, it has been proposed as an excellent “gateway exercise” for sedentary or deconditioned adults wanting to become more physically active.

Meditation is a broad term that incorporates features of self-regulation, awareness, attention, and presence that is typically cultivated through an intentional practice. It has increased tremendously in popularity. Compared to the 2012 NHIS, the 2017 NHIS survey noted that there was nearly a fourfold increase in the use of meditation (4.1%–14.2%). Meditation practices can be broadly categorized as focused attention and open monitoring practices. Focused attention practices, which improve concentration abilities, involve focusing one’s full attention on a designated object of meditation, such as one’s breath. When it is noticed that the mind has wandered from this object, attention is returned to the object. Training the mind, beginning with this basic exercise, has many effects including relaxation, metacognition, cognitive flexibility, uncoupling of painful physical sensations from maladaptive cognitive patterns, and revelation of previously subconscious content. In open monitoring practices, the individual

improves the ability to monitor the contents of experience without any reactions or judgments. This can include other aspects of human experience, such as physical sensations (eg, pain) or mental and emotional states (eg, anxiety). In lay contexts, the word “mindfulness” is often interchanged with or joined to “meditation.” This reflects the ambiguity in the interpretation of these words as well as their cultural origins.

There have been extensive cardiac, respiratory, metabolic, endocrine, and neurological studies of individuals during meditation. Though much remains unknown, it is clear that meditation involves modulation of the autonomic nervous system as well as the hypothalamic-pituitary-adrenal axis, as originally demonstrated in the late 1960s and early 1970s by Dr. Herbert Benson. At the physiologic level, studies of meditation have found effects on the immune system (reduction in pro-inflammatory cytokines), nervous system (enhanced cortical thickness in specific brain regions; neuroplastic changes in the anterior cingulate cortex, insula, temporo-parietal junction, and fronto-limbic network), and endocrine system (reduced cortisol levels). There are also epigenetic changes seen including telomere length and gene expression. From a psychological perspective, it is thought that meditation enables a stable field of awareness around one’s emotions, thoughts, and physical sensations, without reactivity.

In health care settings, one popular application of mindfulness meditation is the mindfulness-based stress reduction (MBSR) program. Originally developed by Jon Kabat-Zinn, this program and its derivatives have been extensively studied in patient populations. It is an 8-week program that introduces mindfulness practice (with Buddhist origins) in a secular, practical form to participants in the context of their life circumstances. This program is intended to create a deliberate, sustained, nonjudgmental way of paying attention to one’s experience in order to enhance self-awareness, change maladaptive thinking, increase the capacity for skillful response to challenges, and reduce suffering. There are now thousands of MBSR programs in the United States and other countries. A close derivative of MBSR, mindfulness-based cognitive therapy (MBCT), was developed exclusively for people with recurrent major depression and has been widely applied to other psychiatric populations.

Meditation-based interventions (MBI) have been found to be useful in the comprehensive treatment of anxiety and depression, along with stress-related conditions. A recent meta-review of meta-analyses supports the notion that

MBIs hold promise as evidence-based adjunctive treatments in a wide range of mental disorders. MBIs show efficacy in treating common cancer-related side effects, including nausea and vomiting, pain, fatigue, anxiety, and depressive symptoms, and improving overall quality of life. A 2020 meta- analysis found that mindfulness-based interventions were associated with reductions in anxiety for at least 6 months after the intervention in adults with a cancer diagnosis. Finally, in individuals with hypertension, meta-analyses have found that meditation can significantly reduce systolic and diastolic blood pressures by 7 mmHg and 4 mmHg, respectively. In subgroup analyses, these findings are particularly striking in patients over age 70. There is a fair amount of heterogeneity in the results; however, they continue to be statistically significant and clinically relevant. Many studies are limited by small numbers, heterogeneous design, and varied clinical outcomes. In addition, it is often unclear as to how adherent individuals are to the prescribed protocols. In meta-analyses very few adverse events have been reported. In summary, meditation can be thought of as a safe intervention, that can be used in a variety of medical conditions that have a stress-related component. While it may not be a primary treatment option in isolation, it can be used effectively as an adjunctive treatment as a part of an overall multidimensional treatment in any chronic medical condition.

Chiropractic is a nationally licensed health care profession that focuses on the relationship between spinal function and general health. The profession was first recognized for its use of manually applied spinal manipulative therapy (SMT) in the treatment of musculoskeletal, as well as many non- musculoskeletal, disorders. In fact, the word “chiropractic” comes from the Greek words cheir (meaning “hand”) and praktos (meaning “done”), ie, done by hand. In addition to manually applied therapies, chiropractors administer soft tissue manipulation, recommend lifestyle changes, engage their patients in rehabilitation and fitness coaching, and provide nutritional counseling. The 2017 NHIS survey reported that 9.5% of adults in the United States over age 65 used chiropractic in the prior 12 months. Back and neck pain were the most prevalent conditions treated by chiropractors.

A significant body of research has focused on one component of chiropractic treatment, spinal manipulation, for a number of conditions ranging from back, neck, and shoulder pain to carpal tunnel syndrome, fibromyalgia, and headaches. Low back pain has received the most research attention and spinal manipulation appears to benefit some people with this condition. The 2017 clinical practice guidelines issued by the American College of Physicians strongly recommended spinal manipulation, based on low-quality evidence, as initial treatment for patients with chronic low-back pain. A systematic review supporting the 2017 clinical practice guidelines for low back pain evaluated 32 randomized controlled trials involving more than 6000 participants and found modest, short-term effects on pain.

The benefit of chiropractic for chronic neck pain is less clear. A 2015 Cochrane review of 51 randomized controlled trials involving a total of 2920 participants concluded that there is some evidence to support the use of thoracic manipulation versus another active control for neck pain, function, and quality of life; however, results for cervical manipulation and mobilization are few and diverse. There is some evidence to suggest that multiple cervical manipulation sessions may provide better relief of pain and improvement in function than certain medications at immediate-,

intermediate-, and long-term follow-up. Because there is risk of rare but serious adverse events for cervical manipulation, more rigorous research is needed on manually applied therapies, and comparing mobilization and manipulation versus other treatment options. There are no high-quality studies that investigate the full scope of chiropractic care for neck pain and the aforementioned studies focus only on one component of chiropractic treatment.

Data on the benefits of chiropractic care for back and neck pain in older adults specifically is more limited. One trial in older adults over age 65 with chronic mechanical neck pain found that SMT combined with home exercise (HE) resulted in greater pain reduction after 12 weeks of treatment compared with both supervised rehabilitative plus HE and HE alone. A follow-up study including older adults with back and/or neck pain that compared a short (12 weeks) versus long (36 weeks) course of combined SMT and supervised rehabilitative exercise (SRE) concluded that extending management with SMT and SRE from 12 to 36 weeks did not result in any additional important reduction in disability; however, long-term management led to greater improvement in neck pain, self-efficacy, and functional ability and balance.

Systematic adverse event monitoring in both studies revealed that no serious adverse events related to interventions occurred. However, nonserious musculoskeletal adverse effects were commonly related to SMT and exercise interventions. The authors concluded that these adverse effects may be regarded as normal reactions to SMT and exercise and should be anticipated and discussed by care providers with their patients. With respect to cervical manipulation, some studies have reported associations between chiropractic care and cervical artery dissection, a rare but serious event. However, the causal nature of this relationship has not been established and is questioned by other studies, which have reported associations between cervical artery dissection and primary care practitioner visits and biomechanical studies which demonstrated that cervical manipulation causes significantly less arterial strain than normal range of motion.

Acupuncture is a therapy in which practitioners stimulate specific points on the body, usually by inserting thin needles through the skin. Acupuncture has origins in TCM, a holistic healing system that includes diet, herbal remedies, mind-body therapies (tai chi and qigong), massage, and acupuncture. From a traditional perspective, acupuncture is based on a system of acupoints, channels and meridians, and flow of vital energy (qi). Within biomedicine, clinical efficacy of acupuncture as well as biological basis and mechanisms of acupuncture have been studied extensively. In terms of acupuncture mechanism, there is no unified theory, although the neural model, most salient for acupuncture analgesia, is most common. Basic science research first reported that acupuncture stimulates the secretion of the endogenous opioid endorphin. Since that first discovery in the 1970s, a multitude of studies have continued to elucidate central and peripheral networks engaged with acupuncture, including those that affect serotonergic and dopaminergic systems, and influence nociceptive pathways and release of interleukins, adenosine, and substance P. For musculoskeletal pain, myofascial stretch, microinjury, increased local blood flow, and facilitated healing may be involved.

Acupuncture has modest evidence of efficacy for treatment or rehabilitation in a wide range of conditions; however much of the literature is inconsistent and has been limited by methodological challenges, including appropriate controls and acupoint specificity. For example, acupuncture may

be a useful adjunct to stroke rehabilitation. Preclinical studies have suggested neurogenesis as a mechanism of acupuncture in ischemic stroke. Systematic reviews and meta-analyses of randomized controlled trials have reported that when added to standard stroke rehabilitation, acupuncture may impact balance function, reduce spasticity, increase muscle strength, and general well-being.

The most robust evidence base has been in acupuncture for pain management. From 1991 to 2009, there were almost 4000 studies of acupuncture, 41% of these for pain conditions. With the opioid epidemic and interest in nonpharmacological approaches to chronic pain, the number of studies has continued to grow. In an individual participant data meta-analysis in 2018 (N = 20,827 patients from 39 trials), investigators concluded that acupuncture is effective for the treatment of chronic musculoskeletal, headache, and osteoarthritis pain. Treatment effects of acupuncture persist over time and have effects above what is seen with placebo. Referral for a course of acupuncture treatment is a reasonable option for a patient with chronic pain. Several other reviews support the use of acupuncture for chronic low back pain. In 2020, the Centers for Medicare and Medicaid Services began coverage for acupuncture services for chronic low back pain.

Most states require a license, certification, or registration to practice acupuncture, and the vast majority of practitioners receive diplomas from the National Certification Commission for Acupuncture and Oriental Medicine for licensing. Some conventional medical practitioners—including physicians and dentists—also practice acupuncture. Practitioners can be identified through national acupuncture organizations, or through referral from physicians and allied health providers. A growing number of hospitals and medical centers now offer acupuncture services, often integrated within pain clinics and oncology programs. The typical course of treatment can vary with conditions, but for common pain conditions, can include 12 to 15 treatments over a 6 to 8 week period.

Ayurveda is the traditional medical system originating from the Indian subcontinent. The practice and education around Ayurvedic medicine were based upon ancient writings that promoted integration between diet, lifestyle,

and stress reduction (including meditation and yoga). It is one of the world’s oldest medical systems. In India, the practice of Ayurvedic medicine is considered part of the health system, and the education and practice of Ayurvedic medicine regulated is under the Ministry of AYUSH. Diagnoses and evaluation in Ayurvedic medicine are made using a systems-based interpretation through an intrinsic understanding of many factors involved in disease manifestation. This includes a constitutional evaluation as well as pathogenic factors, season, and a patient’s entire course of action (diet, drug, and regimen compatible with the constitution) for the expression of the disease. An Ayurvedic clinical examination includes diagnostic methods through inspection, interrogation, and palpation. Ayurvedic treatment combines products (mainly derived from plants, but may also include animal, metal, and mineral), diet, exercise, and lifestyle. In the United States, there are practitioners of Ayurvedic medicine, along with schools and training programs; however, it is presently not an independently licensed profession.

Research in Ayurvedic medicine is limited to studies of individual herbs (eg, turmeric, ashwagandha); there are very few studies looking at it from a systems perspective. Of specific note, some Ayurvedic preparations include metals, minerals, or gems. Previous studies have shown that about one in four supplements tested had high levels of lead and almost half of them had high levels of mercury. The US Food and Drug Administration warns that the presence of these metals in some Ayurvedic products makes them potentially harmful.

Traditional Chinese medicine (TCM) approaches include acupuncture, herbal medicine, moxibustion, and tai chi/qigong. Acupuncture and herbal medicine are two of the most commonly used integrative medicine therapies. While these therapies are covered elsewhere (ie, acupuncture, tai chi), TCM is a systems-based theory that integrates relationships between symptoms, as well as the human body’s relationship with the natural environment. TCM practitioners will discern overall physiological and/or pathological patterns of the human body in response to a given internal and external condition. This is usually a pronouncement of internal disharmony defined by a comprehensive analysis of the clinical symptoms and signs gathered by a practitioner using inspection, auscultation, olfaction, interrogation, and palpation of the pulses.

In the United States, the National Certification Commission for Acupuncture and Oriental Medicine is the certification body that many states use to credential TCM practitioners. Often times, these may be individuals who are also licensed acupuncturists. In many states, the scope of practice for an acupuncturist can include the disbursement of herbal medicines.

Research for herbal medicines used in TCM is increasing. There is promise in TCM in part due to its theoretical framework around holism. Similar to Ayurveda, patient treatments are individualized through reinforcement of the body’s immunity, elimination of pathogenic factors, and improvements in innate healing capacities. However, there have been TCM preparations that have been found to be adulterated as well as mislabeled.

That is, they contain genetic material from animals or plants that were not listed on the packaging. Certain herbs have had serious health consequences. The most notable ones have been ma huang, or ephedra, and Aristolochia, or birthwort. Ephedra, which was marketed as a weight loss medication, was banned by the FDA, as it was associated with sudden cardiac death.

Aristolochia plants contain aristolochic acid, which is a powerful nephrotoxin and human carcinogen associated with chronic kidney disease and bladder cancer.

Traditional Chinese Medicine has shown some promise in the treatment of temporomandibular disorders. In one study women ages 25–55 with temporomandibular disorders were randomized to receive TCM versus specialty care. Those who received TCM experienced greater reductions in facial pain, an effect that was sustained at 3 months.

Integrative medicine utilizes both complementary and conventional health approaches to optimize care of the whole person. In the case of Ms. S, several geriatric syndromes or issues were identified: gait disorder and falls, functional dependence, mild cognitive impairment, polypharmacy, multicomplexity, frailty, depression, and limited social support. Figure 24-3 summarizes the approach to management by the interdisciplinary geriatrics team where each of the eight recommended management approaches is linked via the colored dots to the syndrome it addresses. A mind-body movement- based practice could be considered. In this case, the integrative modality tai chi was recommended given potential benefits for multiple geriatric

syndromes, including gait disorder and falls, functional dependence, mild cognitive impairment, frailty, depression, and social support. In addition, the evidence regarding vitamin E was discussed and the patient decided to discontinue her supplement. Omega-3 fatty acid supplements were discussed as an option, but since the patient met criteria for polypharmacy, she elected not to start taking them at this time. By incorporating multimodal and noninvasive approaches, integrative medicine is poised to play a major role in the promotion of healthy aging and prevention and management of geriatric syndromes.

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Chronic conditions are the major causes of morbidity and mortality among adults in developed countries, as well as the major drivers of health care utilization and cost. In 2020, COVID-19 for a short time was the third leading cause of death in the United States. It affected all-cause death rates and lowered life expectancy. A major risk for severe COVID-19 disease and death, along with advanced age, was the presence of chronic conditions. The management of chronic conditions has been the major focus of health care in the United States for decades, with the goals of preventing the worsening of a chronic disease, decreasing development of related chronic diseases, mitigating associated functional impairment and disability, and decreasing health care utilization and costs. As people age, they confront an increasing number and complexity of chronic conditions and disabilities. Nearly two- thirds (65%) of adults older than age 65 live with MCC, and an estimated 171 million Americans will have MCC by 2030.

For people with chronic conditions, the vast majority of their health care management is done by them in their homes. Even when people have MCC and see many clinicians sometimes many times a month, they still spend the vast majority of their time at home, and are implementing recommended clinical interventions by themselves, or with a family member or care partner, in their homes. Clinicians, researchers, and policy makers have long recognized that patients should not be left alone in their self-management efforts. Self-management support is now understood to be an important

component of ongoing clinical care and that achieving good outcomes of chronic disease management depends on patients’ engagement and partnership in their care. Clinicians, practices, and the health system have roles in assuring that patients and their care partners can self-manage chronic diseases. Because self-management support was not historically considered clinical care, it is only beginning to be reimbursed by payers. Now because it is understood to be central to the management of chronic diseases care, it is often a component of value-based payment models and some self- management support interventions (eg, diabetes education) are reimbursed.

systematic reviews in the literature that demonstrate improvements in outcomes related to self-management support.

The basic premise of patient self-management and self-management support is that self-management is guided by disease-specific guidelines, often based on treatment randomized controlled trials (RCTs) that most often did not include older adults, people with multimorbidity, or people with complex health status. Therefore, clinical management based on these guidelines may not apply to the many older adults with MCC, frailty, or serious, life-limiting conditions. This chapter will explore the complex landscape of chronic disease self-management and self-management support in older adults through the lens of the heterogeneity of the older population. Many older adults are healthy and functional, while some are experiencing severe, life-limiting conditions. There is a big middle group who are accumulating or already have MCC and functional or cognitive impairments and disabilities. Self-management and self-management support interventions, and the clinical paradigms behind them, differ with health status complexity.

This chapter will review foundational behavioral concepts related to self-management of chronic diseases, and how both behavioral theory, and system-based concepts of chronic disease management, have been used to develop, implement, and evaluate disease-specific self-management support interventions.

Finally, it has long been recognized that establishment of a collaborative relationship between clinicians and patients is critical to successful health care. Collaborative and trusting relationships are assuming an even more central place in clinical care as shared decision making and goal-directed care become more prominent ways to sort out the complexity of clinical decision making in patients with multimorbidity. Longstanding health care disparities and inequities in access and quality of health care, broader social determinants of health, and increasing social isolation of many older people can complicate trusting relationships between clinicians and patients, further impeding chronic disease self-management. This chapter will explore what is known about disparities in self-management and self-management support.

Many definitions of self-management of chronic diseases can be found in the literature. It can be defined as patients having the knowledge and skills to accomplish needed tasks to manage their chronic disease on an ongoing, day to day basis; “day to day management of chronic conditions by individuals over the course of an illness”; or “the practice of activities that individuals initiate and perform on their own behalf in maintaining life, health, and well- being, developing the skills needed to decide, implement, evaluate, and revise an individualized plan for lifestyle change.” Lorig and Holman have described self-management as including six key competencies: (1) problem solving; (2) decision making; (3) resource utilization; (4) development of a patient/provider relationship; (5) self-tailoring; and (6) taking action. In this theoretical model, they described three self-management tasks: medical management, emotional management, and role management. Through competencies in these tasks, patients can address aspects of chronic disease management that require self-care, such as attention to appropriate diet and exercise, monitoring and taking medications, doing physiological and clinical activities to monitor effectiveness of management and progress of disease (eg, self-monitoring of weight or blood pressure), getting laboratory,

imaging, or other clinical tests, going to their physician or other clinical appointments, and communicating with family, caregivers, and clinicians. Competency in these tasks can improve self-efficacy, or the confidence a patient has in managing a chronic disease and dealing with any problem or barriers that arise. Embedded in these ideas of self-management and self- management support is a collaborative relationship between clinicians and patients. Old “top down” ideas such as compliance with treatment imply that the patient is a passive participant in their health care. Patients need to be partners in their care for effective chronic disease self-management.

Self-management of chronic diseases is generally distinguished from related concepts that are also quite relevant to the older population such as wellness and self-care. “Wellness” is when a person engages in activities that promote general health such as exercise and healthy nutrition, not necessarily in response to a chronic illness or an identified personal risk of a chronic illness. Self-care is a term for activities that improve quality of life and well-being, such as taking a vacation, meditating, or seeking social engagement. One way to conceptualize how people’s behaviors interact with health and disease is to use the public health framework of primary, secondary, and tertiary prevention. This framework is well-established, although its relationship to management of chronic conditions can sometimes be interpreted in different ways. A common interpretation is that primary prevention occurs before there are any risks or symptoms and signs of disease. Wellness and self-care behaviors would fit into this category.

Secondary prevention addresses risks for chronic diseases, such as smoking cessation, or weight loss to prevent diabetes. Because some conditions (ie, hypertension) can be risks for other diseases, secondary prevention is sometimes invoked in management of these conditions, and patient behaviors addressing secondary prevention are also often termed “self-management.” There are many interventions designed to support people in these activities. Some of the behavioral theories discussed below are also relevant to secondary prevention behaviors. However, this chapter concerns self- management of chronic diseases and will not review the extensive literature related to secondary prevention activities. Self-management of chronic disease(s) generally fits into tertiary prevention, defined as management to alleviate symptoms and prevent complications and/or worsening of chronic diseases that already are clinically evident.

Improving patients’ competencies in chronic disease self-management through self-management support is an important strategy to improve patient outcomes related to chronic diseases, such as improved symptoms, quality of life, and prevention of complications. Self-management support can be considered as a group of tools and techniques that the clinician and/or the health care system can use to support patient self-management. These tools are more than just didactics and education about chronic disease; these tools help patients acquire the competencies and the confidence to handle their condition. Self-management support is sometimes applied to supportive interventions for lifestyle change, such as smoking cessation, weight loss, or increasing physical activity/exercise. The extensive literature on such interventions is beyond the scope of this chapter. Self-management support approaches for substance use are also important interventions and highly relevant to the older population. These are covered in Chapter 23.

Theoretical Frameworks for Self-Management and Self-Management Support Ideas around self-management and self-management support interventions are grounded in two major theoretical frameworks, health behavior theories and models, and models for improving chronic disease management quality and outcomes. Self-management of disease is health behavior, and many clinicians and scholars have considered why people may or may not engage in chronic disease self-management, and how behavioral theory can be applied to enhance patient self-management through self-management support interventions. It is known that self-management of disease is more successful if related to a patient’s goals while it may be less successful if self- management activities are bothersome to the patient and don’t appear to help reach a goal. Patients may also need to cope with barriers (can’t afford medication) or the excessive complexity of some self-management activities. Information and education are needed but not sufficient, and feedback is considered to be helpful.

Behind these familiar ideas are four major theories of health behavior that most often appear in the literature, although there are several others that have been described. The Health Belief Model has been discussed since the 1950s. It is most often discussed in the context of primary prevention. It has four major tenants as shown in Table 25-1, including perceived benefits and barriers related to health behaviors. The model does not account for some key areas of behavior but it has several useful validated components.

TABLE 25-1 ¦ KEY CHARACTERISTICS OF FOUR HEALTH BEHAVIOR THEORIES AND MODELS THAT ARE THE THEORETICAL BASIS OF MANY PATIENT-FACING AND COMMUNITY-BASED SELF-MANAGEMENT SUPPORT INTERVENTIONS

The transtheoretical stages of change model, described by Prochaska and DiClemente in 1982, may be the most familiar model. It is often discussed in relationship to smoking cessation interventions, or invoked in exercise program designs. People pass through the “stages of change,” pre- contemplative to maintenance, as they make a change in their behavior. The stages, shown in Table 25-1, are not necessarily linear, and people can go back and forth between stages. The social cognitive theory, is probably the most widely used as the basis for self-management support interventions. It is a complex and comprehensive behavioral theory that stresses the importance of self-efficacy (a person’s confidence in accomplishing and maintaining a change in behavior despite challenges) and reciprocal determinism (a person is both an agent for change and a responder to change). It connects behaviors to personal factors and environmental factors, and emphasizes the importance of observational learning and self-regulatory behavior. The social-ecological model is consistent with social cognitive theory and stresses the importance of the external environment in behavioral change, and that behaviors can also affect the external environment. It considers multiple external levels—

interpersonal, organization, community, and public policy—and postulates that creating an environment conducive to behavior change will help such change occur.

Self-management support interventions are recognized as an integral component of chronic disease management, and they are often designed, implemented, and studied in the context of multicomponent interventions designed to improve the quality of chronic disease management. Several models are commonly used to guide such interventions (Table 25-2), which are generally implemented and studied in primary care or ambulatory care practices (pulmonary, diabetes, or cardiology).

TABLE 25-2 ¦ KEY CHARACTERISTICS OF THREE COMMON FRAMEWORKS FOR CHRONIC DISEASE MANAGEMENT

The chronic care model was developed as a framework to describe the effective delivery of care for chronic diseases. It considers how the community, health care system, practice setting, and patients interact through six components of chronic care delivery: delivery system design, self- management support, decision support, clinical information systems, leading to a proactive practice team and informed, engaged patients.

The Patient-Centered Medical Home was developed over 15 years ago by the major primary care professional organizations: the American Academy of Pediatrics, the American Academy of Family Physicians, the American College of Physicians, and the American Osteopathic Association. Although it has evolved over the years, it is based on several key principles including continuity and accessibility of care, team-based care, trained and

prepared staff and efficient clinical operation, patient engagement, care coordination and integration, effective health information, and ongoing quality improvement. Similarly, the 10 principles of effective primary care were articulated in 2014 by Bodenheimer as including “4 foundational elements—engaged leadership, data-driven improvement, empanelment, and team-based care—that assist the implementation of the other 6 building blocks—patient-team partnership, population management, continuity of care, prompt access to care, comprehensiveness and care coordination, and a template of the future.” These models are completely consistent with ambulatory geriatric practice and have in common team-based and coordinated care, “whole-patient” orientation, access and continuity of care, and recognition of the importance of ongoing quality improvement. Geriatrics care, however, also explicitly recognizes the challenges of multimorbidity, functional impairment, frailty, and serious illness among older adult patients, which adds even more complexity to chronic care delivery for these patients.

The self-management support interventions that have been implemented and evaluated in the past 15 years are generally based on components of both behavioral change theories and chronic disease management models. Some are more purely behavioral and “patient facing,” while some feature substantial health system redesign; many are multicomponent. Evidence suggests that self-management support interventions are more successful if connected to the health care delivery system rather than only being community based.

Supporting patients in self-management of chronic disease is foundational to improving outcomes of chronic disease management. However, the biggest problem faced by a large minority of older adults, about 40% of Medicare patients, is multimorbidity, and self-management strategies for these patients are much less developed. In older adults, MCC are highly prevalent, produce significant morbidity, and contribute to high illness burden. Among the over 5 million active users of the Veterans Health Administration, nearly 1.5 million (29%) have three or more chronic conditions and about 370,000 have five or more chronic conditions. Half of patients with MCC are 65 years or older.

The effect of MCC on important and well-studied health and health care utilization outcomes, including decreased quality of life, higher mortality, and

increased health care costs are a result of the intrinsically poorer health of persons with MCC.

The premise of self-management and self-management support is different in these multimorbid patients, because most evidence for clinical management is incomplete or absent. A paradigm shift in clinical decision making and chronic disease management is occurring with the recognition that care delivery should be based on the patients’ goals and preferences. Emerging evidence is showing that care that matters to people with complex health care needs is associated with decreased care burden and improved patient satisfaction.

The Limitations of Clinical Practice Guidelines in Older Adults With Multimorbidity

Figure 25-1 illustrates a framework for understanding self-management approaches and challenges across the heterogeneous older adult population. In the idealized world of evidence-based medicine, clinical decision making for patients that leads to clinical interventions and patients’ self-management, is based on evidence from single-disease clinical practice guidelines.

Practice guidelines are typically developed from the best available evidence drawn from narrowly constructed randomized clinical trials. These studies typically focus on a single chronic condition and a target population with tight eligibility criteria. Therefore, most clinical practice guidelines are single-disease guidelines that typically reflect the care of a middle-aged and/or healthy older adult population without significant comorbidities.

When understood from this framework (see Figure 25-1, left side), it becomes clear that guidelines optimize outcomes best when applied to functional adults with few chronic conditions who resemble people in the RCTs and other studies that established the guidelines. For this group, interventions typically prevent disease-specific negative outcomes and promote longevity without substantial trade-offs. The implicit goal of health care within the framework of single-disease guidelines is life prolongation through the elimination of disease. It is for this group, and those guidelines, that self-management is defined and self-management support has been developed and investigated. However elegant this perspective appears, it falters as persons age and acquire additional chronic conditions. Many trials and studies exclude people with MCC, or with cognitive impairment, or people of advanced age, or with serious illness, or with disability, that is,

people with complex health status. For such people the results of the studies cannot be extrapolated.

FIGURE 25-1. Heterogeneity of patients drives appropriate use of guidelines. The heterogeneity among older adults and how health status, including multimorbidity and function, determine the appropriateness of chronic disease guidelines for clinical decision making. HF, heart failure. (Adapted with permission from Blaum CS, Rosen J, Naik AD, et al. Feasibility of implementing patient priorities care for older adults with multiple chronic conditions. J Am Geriatr Soc. 2018;66[10]:2009–2016.)

An alternative approach (see Figure 25-1, right side), focused on symptom management rather than single-disease guidelines, works well in palliative care. Some older people have severe illness, often in the context of multimorbidity, and may be in the last 1 to 2 years of life. For these patients the primary goal is to control urgent symptoms from a serious illness. For these people and their families and care partners, self-management by either the patient or a caregiver must be individualized. There is strong evidence that advance care planning, attention to symptom management, and a palliative care approach are appropriate for this group. However, there is also complexity and heterogeneity among this group. Many people may have advanced cancer or advanced heart failure, where there can be tension between disease-specific management interventions and a palliative approach. The implicit goal of health care shifts in this context to short-term quality of life rather than quantity of life. Guidelines exist for palliative care in people with advanced illness, but they are distinctly different from single- disease guidelines.

Neither of these approaches addresses the decisions faced in the management of older adults with MCC (see Figure 25-1, middle), often with functional impairments, who are not experiencing an imminent, life-limiting illness. Older adults with MCC often describe a broad array of short- and intermediate-term outcome goals. Decision making for their health care often involves trade-offs among conditions and dealing with burdens from managing MCC. Clinical practice guidelines designed for single diseases are simply inadequate in their design and application to be useful for older adults with MCC. These practice guidelines are not adjusted for older adults with MCC, do not consider burden of treatment, and do not factor potential harms from drug-drug, drug-disease, and disease-disease interactions. Furthermore, single-disease guidelines often focus on process measures that are very clinician-centered (eg, lipid screening and HDL control) and often do not target outcomes that matter most (eg, improving mobility and social engagement) to older adults who are self-managing their MCC. While for healthier and highly functional people there are few trade-offs in pursuing disease-specific guidelines, many older adults favor less treatment burden due to possible tradeoffs of harms versus benefits, and risks of treatment impacting competing, personally meaningful outcomes. We cannot rely on health care decisions made on single-disease guidelines applied to older adults with MCC that may create a risk of leading to increased harms and potential injuries.

In middle-aged and healthy older adults who remain functional with few chronic conditions, however, disease-specific self-management and self- management support interventions are relevant. Important and high-quality clinical and health services research has addressed how to translate evidence-based/guideline-based management of chronic disease into practice and investigated whether this improves important outcomes such as decreased symptoms and complications, prevention of disability, decreased health care utilization, and better health-related quality of life. Patient self- management and self-management support interventions have been described and studied as part of the effort to optimize management of chronic diseases, and many self-management support interventions, as discussed below, have been shown to improve selected patient outcomes and have become an

important part of the delivery of care to people who are beginning to develop chronic disease (Table 25-3). Some of the interventions that have been implemented and studied are likely to be applicable as the development and evaluation of self-management support for people with MCC increases. Self- management support interventions for patients with diabetes, hypertension, heart failure, asthma and COPD, and arthritis predominate, but interventions have also addressed stroke, CVD, bipolar disease, depression, rheumatoid arthritis, chronic low back pain, cancer-related fatigue, and use of oral anticoagulants, and many other chronic conditions.

TABLE 25-3 ¦ SELF-MANAGEMENT SUPPORT TARGETS, TYPES, AND STRATEGIES

The published literature is extensive and the behavioral and health services information is well established, with best practices available for implementation. There are multiple scoping reviews, systematic reviews, and meta-analyses that summarize evidence for disease-specific self- management support programs and related models of care.

Many of these interventions have been developed for primary care, although for some conditions they could be implemented in specialty clinics.

Some have been implemented in community settings or use technology, and have variable links to the delivery system. Delivery system interventions are common and include care team member assistance, often a nurse, trained medical assistant, social worker, or pharmacist. Self-management support can occur telephonically, in the clinic, or sometimes in the home. Group visits in the clinical setting especially in diabetes are common self- management support interventions. Other common clinical models use nurse- based interventions, either telephonic/telehealth or in the home (see Table

Community-based self-management support programs are common and have been investigated extensively. These are often purely patient facing and may or may not link to the clinical delivery system; multiple intervention types are represented in the literature. These can feature group visits (common in exercise or physical activity programs and weight loss), classes, peer counseling, use of technology such as automatic phone calls, websites or smart phone/tablet apps, videos, or intermittent mailings.

Technology and health IT-based interventions are becoming increasingly used and tested for self-management support and directed toward patients (although they can also be directed toward clinician behavior). Besides those mentioned, increased patient use of the EHR with increasingly interactive patient input, may influence patient self-management through better communication with clinicians. Patient portals are widely available with increasing patient uptake and patients can now read and add to clinical notes. Smart phone or tablet apps have become widely used for self-management support and have been evaluated in multiple systematic reviews and meta- analyses. In some early adopter systems, phone or tablet apps used by both patients and providers can seamlessly connect to EHR workflow and these types of connections will become much more widespread as digital interoperability among different platforms for health data, particularly patient generated data, improves.

Other types of chronic disease management interventions are less commonly used in self-management support interventions, although financial incentives for patients have been implemented and studied (eg, gift cards or money for hypertension control).

Below is a brief overview of some of the more common self-management interventions that have been tried in specific chronic diseases. There are many more examples in the literature but those below represent self- management support interventions that can often be found now in primary care or other ambulatory practices.

Diabetes Diabetes is the target of many existing self-management support programs and the disease most often targeted in published self-management support interventions. Multiple types of interventions have been studied and many are effective on some relevant outcomes. Diabetes Self-Management Support (SMS) can be community based, educational, connected to the primary care or diabetes clinic, use technology, or be a combination of methods. Mobile phone and tablet apps are commonly used in diabetes with many descriptions of such programs and reviews in the literature. Diabetes self-management education has been shown to improve outcomes and Certified Diabetes Educators are reimbursed for this activity. Community- based educational and task competency interventions have been shown to improve patient level outcomes. There has been some attention to self- management support for diverse populations and the CDC has reported that diabetes self-management support is effective in Hispanic patients. Multiple diabetes self-management apps are available for mobile phones, some of which are sponsored by the American Diabetes Association.

Arthritis The first major SMS program based in behavioral theory was the Arthritis Self-Management Program (ASMP) developed by Lorig in 1979. The behavioral foundation of ASMP is social cognitive theory and the development of patient self-efficacy. The program consists of several sessions with trained facilitators and teaches medication management, communication with health care providers, strategies to cope with pain, nutrition, and exercise. It has been evaluated for decades and has been shown to improve patient self-efficacy, self-management behaviors, and possibly general health status, and it has been reported to be associated with cost savings.

The Chronic Disease Self-Management Program (CDSMP) Based on the success of the ASMP, Lorig and colleagues at Stanford applied similar behavioral concepts to self-management support for several diseases, including diabetes, cardiovascular disease, pulmonary diseases, cancer, pain, and HIV, because the skills taught can apply generally to chronic diseases. The different self-

management support programs maintain the same format of several sessions with two facilitators and teach similar skills. After many years as part of Stanford University, the Chronic Disease Self-Management Program is now a non-profit called the Self-Management Resource Center (SMRC) that licenses and trains facilitators to implement the program throughout the country. It has relatively broad dissemination.

Hypertension and cardiovascular disease (CVD) CVD continues to be the major cause of death and a significant contributor to morbidity and mortality, and as such has been a major target of SMS interventions. Hypertension is highly prevalent with substantial benefit of treatment. Multiple intervention methods have been used in both, including nurse telephonic support, group visits, and the CDSMP behavioral approach. Mobile apps are thought to be an important tool for hypertension self-management and multiple studies evaluating their use are available. A brief scan of mobile device app stores demonstrates multiple self-management apps for hypertension and CVD.

Heart failure (HF) HF is generally a disease of older adults, whether associated with reduced or preserved ejection fractions. The morbidity, utilization, and mortality associated with heart failure have been a target of disease management programs, self-management support interventions, care delivery redesign, and much clinical and health services research for decades.

Despite all this focus, outcomes for HF patients have improved only slightly, and reviews of disease management programs show small to moderate effects on some outcomes. Patients’ self-management in HF is complex, and patients must recognize symptoms, manage diet, physical activity and complex medical regimens, recognize and react to physiological changes, and interact with caregivers and clinicians. SMS has generally been included within a multifaceted disease management program that is connected to clinical care, remote monitoring, telephonic/telehealth support, and sometimes home visits. A 2017 Cochrane review cataloged a wide variety of HF disease management programs that included self-management support, and reviewed multiple outcomes where some successes were noted. Now, however, it is widely recognized that fewer than 5% of HF patients only have HF and most patients have five to six comorbidities, often including cognitive impairment, complex health status, and limited life expectancy.

Many of these HF patients may fit into a different paradigm of self- management related to their multimorbidity, with attention to goals and preferences.

COPD Self-management support interventions for COPD also feature several models. Similar to other chronic diseases, the CDSMP approach, patient education, and telephonic support are used. Patient action plans and technology approaches providing education and digital management support are also available.

Obesity While clinicians and experts in metabolism and nutrition can debate whether obesity is a disease, there are many self-management support interventions that target weight loss. However, the picture in older adults is not always clear and there is evidence that a body mass index (BMI) in the “overweight range” is protective for older adults. There is likely a U-shaped relationship of BMI index in older ages, where very low and very high BMIs are associated with poor outcomes. Body composition changes with age and loss of muscle appears to occur with aging leading to sarcopenia (discussed in Chapter 30). Weight loss can impact both fat and muscle; loss of muscle mass can exacerbate sarcopenia. Fat composition also changes with age, and even at a relatively low BMI an older adult may have excess fat relative to muscle mass. In obese older adults, sarcopenic obesity, where there is low muscle mass in the setting of obesity, and “fat frailty,” where obese older adults meet various criteria defining frailty, have been described and are associated with poor outcomes. The picture may also be confused due to unintentional weight loss that is common in older adults either due to chronic diseases or unmet personal care needs. Studies that have combined weight loss with exercise, in diabetes interventions for example, have shown improved outcomes related to mobility and metabolic parameters. For the “young” old, where obesity is impacting chronic diseases such as diabetes and hypertension, weight loss programs similar to those for middle aged people are likely appropriate and there is an extensive literature in this area. However, it is incumbent upon the geriatrician and clinicians caring for older adults in general to understand when the picture becomes more complex as people age, accumulate MCC, and demonstrate changes in body composition.

Because self-management support is an integral component of the management of chronic diseases, major systematic reviews and meta- analyses often include self-management support within a suite of “disease management” interventions, which can be at the delivery system level,

community level, clinician level (which can be multidisciplinary—physician, nurse, social worker, pharmacist, etc.), and patient level. There is debate over what outcomes should be considered in these evaluations, and different studies consider different outcomes. Outcomes that are evaluated are generally in three program categories: system level, provider level (such as provider behavior), and patient level. Patient level outcomes are the target of self-management support. Common patient level outcomes include: adherence to treatment, physiological markers of disease, risk behavior, quality of life, mental health status, satisfaction, function, knowledge, medication use, and health services use. Costs are also sometimes evaluated. Systematic and formal meta-analytic reviews usually tackle the entire disease management program, and use a variety of outcomes related to components of the chronic disease model, or Cochrane Organization’s Effective Practice and Organization of Care (EPOC) taxonomy. The EPOC taxonomy considers outcomes related to multiple practice domains and sub-domains including care implementation strategies, service delivery interventions, and financial and governance arrangements. Some reviews, however, drill down to specific components of a self-management support program, evaluating interventions involving apps, telehealth, nurse led, peer led, community based, educational, group visits, home visits, and others.

A recent review of self-management support for chronic diseases, while not focused specifically on older adults, concerns behavioral self- management support, and provides an understandable guide through the evidence for the effectiveness of these interventions. It considers recent Cochrane reviews of self-management support interventions in diabetes, CVD, asthma, and arthritis and has a concise review of the behavioral foundations of self-management support interventions. It concludes that these interventions have a low to moderate effect on important outcomes on health behavior, health status, and health care utilization for selected chronic conditions.

Several systematic reviews focus on self-management support interventions in primary care. One evaluated 58 studies of self-management support in primary care in order to identify effective strategies within the interventions, and the impact of the interventions on multiple patient outcomes. Self-management support was conceptualized as a “portfolio of techniques and tools” that patients and care partners can use as they self- manage chronic disease, as well as a realignment of the patient/clinician

relationship so that the patient is fully engaged and a true partner in disease management. The review assessed self-management support interventions that addressed many single conditions—diabetes, COPD, and depression were the most common. Several themes of successful self-management support interventions were identified that emphasize its multicomponent nature. Components of successful interventions include patient goal setting, personalized interventions tailored to patient needs, combinations of strategies to improve patient knowledge of the disease as well as techniques for monitoring symptoms and disease activity, coping and stress management strategies, problem-solving and decision-making skills. Eighteen outcomes were evaluated, and disease-specific and quality of life indicators were most often favorably affected.

Another review of chronic disease management interventions in primary care assessed self-management support as one of the several chronic disease management interventions. This review demonstrated that self-management support was among several interventions for chronic disease management; others include delivery system design changes and clinician decision support. Findings were that self-management support was both the most commonly studied intervention and had the most effect on patient outcomes, particularly for diabetes and hypertension. Self-management support interventions were found to improve patient level outcomes of physiological measures of diseases, risk behavior, satisfaction, and knowledge.

There are also multiple reviews of separate components of self- management support interventions such as nurse led interventions, peer support, and shared medical visits. One systematic review and meta-analysis of nurse led interventions reviewed 29 studies, most from the United States but some from the EU and Australia. It reviewed the effectiveness of a wide range of nurse led interventions including telephonic, in home, in clinic, and involvement by advanced practice nurses and RNs. Content included educational programs, problem solving, and self-management skills development. Most interventions involved hypertension and diabetes, and physiologic markers of disease were the outcomes most often improved (BP, HbA1c). Effects on quality of life and mortality were inconclusive. This review noted that self-management support programs that featured specially trained nurses were more effective. It also noted that nurse led self- management support was not effective in people with multimorbidity.

The literature has many studies and several reviews of peer support interventions. Peer support is generally used to support self-management of cardiovascular disease risk factors and diabetes. Although the evidence is mixed, peer support shows promise in these areas. Evidence suggests it improves glycemic self-management and systolic blood pressure in diabetes, and decreases cigarette smoking in people with cardiovascular risk factors.

Shared medical visits, often called group visits, are common in many current primary care settings. They have been used for over two decades for several conditions, but in middle aged and older adults they mainly focus on diabetes. A major review by Department of Veterans Affairs researchers in 2012, updated in 2014, found some evidence for effectiveness in glycemic control and diabetes knowledge. However, no evidence was found about subgroups who might benefit more, patient satisfaction was not different in those with shared medical appointments, and there was insufficient evidence to assess the relationship of the intensity of the intervention (length of time, group size, medication changes, follow-up visits) to outcomes. A general systematic review of shared medical visits again noted the predominance of such visits in diabetes and findings were consistent with the earlier VA evaluations.

Technology use is a big part of self-management support interventions in current clinical settings, and evaluations of its effectiveness are ubiquitous in the literature. A 2017 metareview (ie, a systematic review of systematic reviews) of telehealth interventions for diabetes, hypertension, heart failure, COPD, and asthma reviewed 56 systematic reviews and 256 studies.

Findings were that the systematic reviews were inconsistent, and some but not all showed improved physiological markers of disease.

In the past few years, mobile phone and tablet apps have been used in and studied clinical settings. These technologies have been used most in diabetes, obesity, COPD, and hypertension. A brief scan of PubMed will yield many systematic reviews and meta-analyses from around the world. Most reviews show acceptability and feasibility, but the studies tend to be short-term and many do not use rigorous methodology. Despite some positive results in some reviews, the general consensus is that the effectiveness remains unclear. Regardless, in the current clinical environment, apps are often used by patients for self-management and, when connected with a clinical program providing feedback, for self-management support. The developing interoperability environment that will digitally connect data from

mobile apps to the EHR could potentially improve mobile device supported self-management.

Clinicians and investigators have begun to consider the theoretical foundations and some interventions regarding self-management support for patients with MCC. There are several systematic reviews in the literature related to clinical and community interventions that attempted to improve outcomes for patients with multimorbidity. A broad range of diseases were considered part of multimorbidity interventions, but diabetes, hypertension, depression, CVD, and COPD were most often included. An example of such reviews is a 2017 Cochrane review, updated in 2021, that considered interventions in primary care and in the community using the EPOC framework. It included both randomized and nonrandomized interventions reported from 1996 to 2015. The self-management support interventions evaluated were similar to those for single diseases. Most studies included either delivery system changes, such as case management by nurses or other care team members, or patient-oriented self-management support such as educational programs. The results of these self-management support interventions included: (1) no effect on clinical outcomes and utilization; (2) mixed effects on medication use, some patient reported outcomes such as quality of life, and health behaviors; and (3) improved mental health outcomes (when depression was one of the included diseases) and clinician behaviors. Confidence in the outcomes found was generally judged as low or moderate, although the impact on depression was high.

Given the modest to small impact of self-management support on improving care for people with multimorbidity, there is broad recognition that clinical management of people with MCC/complex health status, including self-management support, is inadequate and does not improve the quality of care for multimorbidity patients. A recent review presented a thematic analysis of observational and qualitative literature addressing self- management challenges for people with complex health status, defined broadly. Their screening process identified 22 articles from 980 papers screened, from which they identified six themes: need for prioritization; lack of motivation; risk for depression; risk of poor self-efficacy; increased risk of receiving conflicting information; and opportunity to use personal experience. A systematic review and expert consensus by an international

and interdisciplinary group reviewed eight international guidelines of clinical principles for management of multimorbidity and polypharmacy and identified 246 recommendations. The consensus panel summarized all this information into four guiding principles, and each guiding principle was associated with a self-management approach. The self-management principles included: establishing the self-management burden in the context of the persons’ capacity and need for support; encouraging patients to clarify goals, values, and priorities; considering use of individualized care plans and medication plans, telehealth use, and care coordinators; and assuring review and follow-up of self-management plans, particularly related to medication-related concerns.

HF, whether with preserved or reduced ejection fraction, is nearly always associated with multimorbidity. A recent systematic review evaluated 14 studies that assessed self-management of HF with reduced ejection fraction in people with cognitive impairment. The involvement of family and care partners was not emphasized. The review found that cognitive impairment predicted poor self-care ability, self-care maintenance, disease management, and self-confidence. Cognitive impairment contributed to poor engagement in self-care, worse health outcomes, and increased mortality.

The complexity of HF self-management, and the ubiquity of multimorbidity in HF, led leading HF clinical researchers to develop a “pragmatic framework to optimize health outcomes HF and multimorbidity.” They noted that many HF self-management support interventions are directed only toward HF and fail to account for multimorbidity, and that multiple studies have shown disappointing outcomes from that approach. These investigators maintain that five steps to reorganize HF self-management support could potentially improve HF outcomes: “1) acknowledge multimorbidity; 2) profile hospitalized HF patients for multimorbidity; 3) identify priorities and patient-centered goals; 4) support individualized home-based case management to supplement standard HF management; and

Self-Management and Self-Management Support in Diverse and Underserved Populations

As reviewed above, the effectiveness of self-management interventions for single chronic conditions is modest or, in the case of multimorbidity,

generally small, although in some cases there are important favorable patient outcomes. Unfortunately, effectiveness is further diminished among racial and ethnic minorities, lower income groups, and those living in rural areas.

Inadequate housing, food insecurity, and financial challenges make self- management of chronic conditions difficult, even assuming health care access. However, health care access is often inadequate in low-income areas, and mistrust of the health care system, and dysfunctional provider/patient relationships certainly complicate the ability of some Black, indigenous, and people of color and immigrant people with chronic diseases to self-manage chronic conditions, whether they have one or many.

Interventions featuring community support, perhaps designed for community health centers using culturally appropriate self-management support strategies, are needed to improve both access and effectiveness of self-management and self-management support in populations with health disparities. Strategies that use more common health information technology like mobile phones hold potential promise. Telemedicine and telehealth approaches that incorporate health educators and health professionals are more effective because they mirror the structure of other evidence-based management approaches while broadening access. Formal involvement of family and friends in self-management support is another strategy for improving the outcome of self-management among minority populations. An ecological approach that involves social networks and social support (especially group-based interventions) for self-management and health behaviors may improve the outcomes of chronic illnesses in minority populations. Augmentation with technology, such as proactive calls from a nurse educator, may further enhance reach and adoption given the difficulty of attending in-person group visits among all populations.

Evidence for self-management interventions targeting older adults with multiple morbidities from minority populations is minimal. However, a few insights drawn from other studies suggests that a focus on whole-person functional status and symptoms is important. An ecological approach that places a vulnerable older adult within the context of a family and community for self-management support is likely critical. Communities of color and other disadvantaged populations will benefit from the integration of community resources, such as community health centers, into the design and delivery of self-management interventions. The use of widely available technologies that augment reach, access, and adoption hold promise for

improving the uptake and outcomes of self-management interventions, especially for older, multimorbid, and minority populations.

Deficiencies of Current Self-Management and Self-Management Support Interventions in People With MCC

Many clinicians, investigators, and experts, supported by the emerging literature, realize that the current approach to self-management and self- management support for patients with MCC, based on managing chronic conditions by adherence to single-disease clinical practice guidelines, is inadequate to improve outcomes for these patients. Among potential reasons why this may occur, three stand out. First, older adults with MCC are at increased risk of adverse outcomes from the application of multiple clinical practice guidelines, including drug-drug, disease-disease, and drug-disease interactions and the harms of polypharmacy. These adverse outcomes may be of greater importance than the disease-specific outcomes that guidelines often target. Self-management support for all of their conditions based on disease- specific guidelines could well increase adverse events. Second, clinical practice guidelines fail to focus on outcomes most important to older adults, including living independently in one’s home, increasing physical function, and engaging in meaningful social relationships. People may not be engaged in self-management that does not help them achieve the outcomes they care about. Third, older adults, caregivers and clinicians are burdened by the workload of multiple disease-specific interventions, and may wish to decrease this burden, particularly when the workload is not aligned with the goals of the older adult and caregiver. Self-management support interventions may sometimes actually add to this burden.

The presence of MCC exposes an older adult to significant risk for adverse outcomes arising from acute exacerbations from a serious illness and interactions of one or more chronic illnesses. This burden of multimorbid illnesses is defined as the “cumulative impact on the older adult from numerous acute and chronic diseases and general impairments, affecting multiple domains rather than a single organ system or isolated impairment.” High levels of illness burden significantly impact quality of life, daily functioning, symptom burden, and carry a significant economic impact on personal finances.

In addition to the burden of illness, adults with MCC face an excessive burden of treatment that impacts their daily life, relationships, and well-

being. Multimorbidity imposes burdens on older adults and their caregivers related to frequent health system interactions, demands for self-care activities, and medication burdens from polypharmacy and drug interactions (Table 25-4). Burden of treatment consists of the everyday demands arising from interacting with the health system and frequent clinician visits, negotiating conflicting information about symptoms and treatments, adapting recommendations into daily routines, managing medications, and relying on supportive services.

TABLE 25-4 ¦ PATIENT SELF-MANAGEMENT ACTIVITIES

Patients with MCC and their family caregivers spend 2 hours a day on self-care plus an additional 2 hours for every visit to a health care facility (ie, travel time, wait time, and time receiving care). Patients with Medicare typically visit five or more specialists annually. Higher burden is associated with poor medication adherence and morbidity. For older adults with cognitive and functional impairment, the capacity to manage the complexities of treatment is often diminished. Over time, the persistent imbalances between complexity and capacity create stress, fatigue, and inability to perform necessary care tasks, which then results in poorer health outcomes. Burden of treatment for older adults with MCC is not only considered a harm in and of itself, but also impacts health care access, use, self-management, and health outcomes.

A paradigm shift in clinical decision making that results in the provision of the appropriate amount of care is needed to achieve what matters most for older adults and their families. An approach that focuses care on what matters most for older adults rather than adherence to single-disease guidelines holds more promise for increasing quality of care for patients with multimorbidity, and is likely to increase engagement and partnership with clinicians and reduce self-management burden, allowing patients to achieve health outcomes that matter to them. Several approaches have been described and are diffusing throughout the delivery system where people with multimorbidity receive care. One is the Veterans Administration Whole Health Program (Figure 25-2), which focuses on the array of health, social, spiritual, and wellness needs of whole persons rather than a narrow focus on prolonging life and eliminating symptoms.

FIGURE 25-2. Veterans Administration Whole Health Program. The Veterans Administration’s Whole Health Program provides a whole-person, patient-centered, comprehensive view of health, and its components are described within circles. For example, the “Me” component involves the patient’s identification of ‘what matters most to you’ and working toward a personal health plan by identifying missions, aspirations, purpose, and shared goals. The next circle is your self-care. These are the circumstances and choices you make in your everyday life. The next circle represents professional care you receive. Professional care may include tests, medications, supplements, surgeries, examinations, treatments, and counseling. This also includes complementary approaches such as acupuncture and mind-body therapies. The fourth circle represents the people and groups with whom you are connected. (Data from US Department of Veterans Affairs Whole Health https://www.va.gov/WHOLEHEALTH/circle-

Investigators have demonstrated that older adults with MCC describe a consistent set of health-related priorities (“what matters most”) that typically include: social and spiritual engagement; function and independence; life enjoyment activities and roles; and managing health that balances quality with quantity of life. Older adults with MCC report wanting their clinicians to know their priorities (and assume they do know them), but few patients describe having specific discussions about their priorities. Outcome goals that help older adults with MCC live according to what matters most to them, within the context of what treatments they are willing and able to engage in,

should be the basis for guiding treatment decisions and subsequent patient self-management efforts. Such an approach is much more consistent with the foundational definition of patient-centered care.

Another prominent approach is Patient Priorities Care (PPC) (Figure 25- 3), which also seeks to align clinical decision making for people with MCC with their health outcome goals and care preferences to deliver care that matters to people.

FIGURE 25-3. The key steps involved in Patient Priorities Care are illustrated. Patient health priorities are identified either through a self-directed process (https://myhealthpriorities.org/) or with a health professional. The health priorities are transmitted to the patient’s clinician who then considers whether current or potential interventions are consistent with patient’s health priorities. Clinicians and patients align care with the identified health priorities by using the patient’s priorities as a focus of communication and decision making, as a target of serial trails to start, stop, or continue care, and to reconcile decisions when different perspectives exist. Self- management support is provided to assist the patient if necessary to carry out the clinical interventions that will help the patient achieve or make progress on her/his priorities. (Reproduced with permission from Mary Tinetti and Aanand Naik 2021.)

The key premise of such approaches is that people are much more likely to engage in their care, partner with clinicians to achieve the goals that matter to them, and self-manage care that respects and aligns with their preferences, when they are willing and able to achieve their goals, that is, what matters to them. The PPC and the whole health approach are completely consistent with health behavioral theories for successful patient chronic care self- management: care that stresses goal setting, patient communication and engagement with clinicians, self-efficacy, and removing barriers to care.

The case scenario presented illustrates the problems a patient with MCC can face in self-management, and how a new approach to clinical decision making and care delivery can simplify his treatment burden, and direct self- management and self-management support toward his personal health outcome goals.

Case scenario: Older adult with MCC Mr. T is an 80-year-old man with type 2 diabetes, hypertension, and stable congestive heart failure (ejection fraction of 40%) who is presenting to his primary care physician today for follow-up. Additional comorbidities include osteoarthritis of his knees, benign prostatic hypertrophy, and age-related macular degeneration. His wife accompanies him to the visit. Mr. T is independent in all activities of daily living but has mobility impairment requiring a cane and has trouble with stairs. He needs assistance with some of his instrumental activities of daily living; his wife does the housekeeping, driving, shopping, and cooking. He manages his medications.

Over the past several months Mr. T’s blood pressure has been at goal. His hemoglobin A1c values have been between 7.5% and 7.8%. He saw a podiatrist within 6 months, but he has missed two ophthalmology visits over the past year. He is taking two oral hypoglycemics as well as insulin, five evidence-based medications, and three medications for symptoms. He has six specialists.

Mr. T’s primary complaint over the past few months is that he is weak and tired. He has been skipping church, where he was very active for years, because he can’t climb up steps. A medical evaluation has ruled out acute illnesses or new conditions. Side effects of medications are being considered as contributing to some symptoms. Mr. T has been getting mixed messages from his health care team. His primary care clinician decreased his beta- blocker, but his cardiologist increased the dosage again. The primary care clinician then initiated a trial of decreasing Mr. T’s insulin, but his endocrinologist increased the insulin at a later visit.

Mr. T and wife are frustrated with conflicting recommendations and he states that he does not feel any better. His wife is stressed and angry that his clinicians “can’t get on the same page.” Both Mr. T and his wife say that “we don’t know who to listen to and it scares us—we don’t know the right thing to do.”

The primary care physician is also frustrated with the conflicting recommendations and concerned that the patient has missed several

appointments and may start skipping some meds. What Mr. T wants from his health care is to have more energy, go to church, and have less “work of being a patient.” Is this approach to managing Mr. T’s chronic conditions, while guideline-driven and well-intentioned, helping Mr. T and his wife?

How do Mr. T and his wife decide upon and implement self-management tasks, given conflicting recommendations, treatment burden, and their realization that the treatments for all his conditions are not helping him do what matters to him.

Management of MCC Including Self-Management Support for Mr. T Management of Mr. T’s multimorbidity would be based on delivering care that matters to Mr. T and helping him achieve his health outcome goals while respecting his care preferences. Such support would be connected to his primary care or geriatrics practice, or perhaps the practice where he receives most of his care (eg, cardiology, endocrine). The practice would include team-based care and a member of the care team, perhaps a nurse, social worker, care management professional, or other team member, and would coordinate Mr. T’s self-management. Self-management support activities would be incorporated into several care delivery components that could include:

Care for chronically ill older adults would benefit from a personalized, person-centered approach whereby clinicians recommend primarily the care that achieves the outcomes that matter most to an older adult (ie, outcome goals) while being consistent with what the person is willing or able to do to achieve those outcomes (ie, care preferences). PPC is a clinical approach, developed and validated by a multidisciplinary clinical team that identifies the priorities of an older adult and then aligns treatment decisions to achieve

those identified priorities. Patient priorities refer to the specific health outcome goals that individuals most desire from their health care given what they are willing and able to do to achieve these outcome goals within the context of their preferences. Patient priorities encompass: (1) health outcome goals—the health and life outcomes that people desire from their health care, and (2) health care preferences—health care activities (eg, medications, self- management tasks, health care visits, diagnostic testing, procedures) that people are willing and able (or not willing or able) to perform and the care they are willing (or not willing) to receive. To inform decision making, outcome goals should be specific, realistic, and timely and aligned with what matters most to the individual (health-related values).

PPC is a structured process (see Figure 25-3) whereby a health care professional first guides an older adult through a clinical encounter to

identify her/his priorities. The health care professional documents the patient priorities within an electronic health record (EHR) and transmits them to the clinician. Second, clinicians review the priorities to decide which current therapies should be changed, enhanced, or stopped, and which new treatments or care options should be considered to better achieve the identified priorities, aligning health care to meet patient priorities rather than disease endpoints. In the third step, the clinical team monitors how management is working to help the patient achieve priorities, and

communicates these priorities and the aligned clinical care to all people involved with the patient’s care, including the patient and family/care partner.

The feasibility and effectiveness of the PPC approach has been demonstrated in a nonrandomized clinical trial within a large private practice with primary care providers and cardiologists. Compared to usual care (UC), patients in this study reported greater reductions in treatment burden (ß = -5.0; p = .01) and more deprescribing (odds ratio = 2.05 [1.43 - 2.95]). A subsequent pilot study adapted PPC for a VA geriatrics clinic setting, and found similar results. These results suggest PPC is effective at reducing burdensome care (eg, inappropriate medications) and recommending a wider range of care (including home and community services and supports) that aligns with priorities. Furthermore, PPC is innovative by focusing on care that achieves patient priorities rather than clinical practice guidelines.

Similar to the PPC approach, the Department of Veterans Affairs cultivated VA Whole Health—an innovative approach to care that supports the health and well-being of veterans. The VA Whole Health approach has gained traction and now exists at all VA facilities across the country. The VA Whole Health approach is not specific to the care of veterans; it is applicable to all patients who desire care that is focused on “what matters to you, not what is the matter with you.” The VA Whole Health approach begins by guiding veterans through the process of developing a personalized health plan based on what matters most. The process is facilitated by a whole health coach who guides the veteran by first exploring the Circle of Health (https://www.va.gov/WHOLEHEALTH/images/components-of-whole- health.svg), which is a structured process for exploring health-related values. Using the circle of health, veterans can complete their personalized health plan which also includes shared goals and health care preferences. The personalized health plan encourages veterans to expand their health care options beyond traditional health care services including alternative and complementary care, yoga and acupuncture, multimodal pain management, exercise, and nutrition. The VA Whole Health program has made tremendous strides in impacting the care of younger and middle-aged veterans. The program is now working with the VA Geriatrics and Extended Care office to address the needs of older veterans, including a partnership with the PPC developers.

An expanded understanding of what older adults would like to achieve from their health care often involves more self-management support than the traditional medical system offers. Community-based self-management support can be provided by community-based services that support multimorbid patients and their families/care partners in self-management of chronic conditions including functional or cognitive impairment. For example, the VA implementation pilot for PPC noted increased use of home and community services and supports as complementary services to align with and achieve patient priorities, generally through supporting self- management of the wanted care. Home and community-based services and supports, including adult day services and home services (skilled nursing, physical therapy, homemaker) are increasingly recommended in VA to help older adults achieve outcomes that matter to them. Personal care support for instrumental and basic activities of daily living are important interventions

for helping people achieve goals that matter and also provide self- management support of chronic diseases. Treatment recommendations that promote the use of home and community based long-term services and supports aligned with patient priorities are not only patient-centered but also beneficial to the health system.

PPC and the Whole Health approach to care provide a conceptual and empiric foundation for moving the focus of care away from strict adherence to clinical practice guidelines and inappropriate care delivery and self- management expectations. The alternative motivation for health care lies in an emphasis on the priorities of older adults, defined concretely as outcome goals and what patients are willing to do to achieve their goals (care preferences). Self-management and self-management support would be directed toward helping the patients achieve their goals, given their care preferences. Adherence to evidence and practice guidelines remains important but only as a means to achieving patient priorities rather than the primary measure of health care quality.

There remain other issues to face regarding how to support people with multimorbidity in their self-management of chronic diseases and conditions in order for them to achieve their goals. Important problems include: how to involve and support families and care partners in helping patients’ goal achievement: how to disseminate new care approaches for multimorbidity management to different clinicians; how to incentivize providers to both deliver care that matters and follow up with clinical decision making and care plans that help patients achieve their goals; and how emerging technological capabilities, especially EHR communication between clinicians and patients, and interoperability among EHR systems and mobile technology, will impact self-management and health outcomes of patients with multimorbidity. Emerging approaches to care of patients with MCC, focused on patient-defined health outcomes, that support patients’ self- management to achieve their own goals hold promise to improve chronic disease management and, most importantly, outcomes that matter to older people.

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The law regulates human relationships prospectively and retrospectively in a variety of ways. To a large extent, the legal implications of medical practice are generic, in the sense that they apply to patients of all ages. Rules developed to deal with the care of younger adults apply with full force to older persons, whose rights do not diminish just because of advanced chronological age. However, a patient’s advanced years may raise issues demanding particular attention by involved participants in the professional/patient relationship. This chapter concentrates on selected aspects in which the law influences the delivery of geriatric services through its impact on the recognition and enforcement of respective rights and responsibilities of the parties, within the dynamics of an older patient/health care provider relationship.

The U.S. Constitution establishes a federal system of government, under which health care delivery, financing, and other matters are regulated at the national (federal), state, and local levels. Under separation of powers principles, regulation takes the form of (1) constitutional (federal, state, and local) provisions, (2) statutes enacted by elected legislatures, (3) rules or regulations promulgated by executive branch administrative agencies such as health or social service departments on the basis of authority conferred on the agency by the legislature via statute, and (4) common law doctrines created by courts as a matter of public policy and prior case precedent.

These various forms of regulation may impose specific or general duties on parties, may authorize but not require parties to act in specific ways, or may prohibit parties from engaging in particular conduct. Health care regulation may be directed at individual health professionals or at health care facilities, agencies, institutions, and other organizations.

One primary mechanism for regulating health professionals to assure adequate qualifications and acceptable conduct is licensure, which entails the requirement that an individual satisfy—on both an initial and continuing basis—certain enumerated standards to be permitted to practice a particular profession. Professional licensure ordinarily occurs at the state level through statutes (such as state Medical Practice Acts or Nursing Practice Acts) and regulations promulgated by a state’s licensing body (such as the Medical Board or Nursing Board) to implement the Practice Act. Licensure statutes and regulations limit certain activities to licensed professionals; engaging in those activities without prior state approval is practicing medicine or nursing without a valid license and subjects the wrongdoer to civil fines and potential criminal sanctions.

Many statutory and regulatory requirements or prohibitions imposed on health professionals occur as conditions attached to payment for professional services under government insurance programs, especially Medicare and Medicaid. Professionals who treat patients covered by these government programs must satisfy the positive (eg, “Thou shalt” maintain adequate patient records) or negative (eg, “Thou shalt not” engage in self-referral) strings placed on the payment of public dollars to receive compensation for services rendered.

Another manner of health professional regulation under the civil law is tort liability in private lawsuits claiming malpractice (discussed below).

Particularly egregious, intentional misbehavior (such as patient abuse or billing fraud) may subject a health professional to criminal law punishments.

Significant regulatory sanctions imposed on certain health professionals, as well as any monies paid on behalf of a health professional as a result of a professional liability claim, must be reported to the federal Department of Health and Human Services’ National Practitioner Data Bank (NPDB). An individual’s NPDB file is confidential except in circumstances specified in federal regulation.

Besides regulating individual health professionals, government regulates provider facilities and agencies through licensure requirements, conditions attached to compensation under public insurance programs including

Medicare and Medicaid, criminal prohibitions on specific behaviors such as the filing of false claims, and civil liability for malpractice claims brought by or on behalf of individual patients. For example, Congress enacted the Nursing Home Quality Reform Act, 42 US Code §#1395i-3(a)-(h), as part of the Omnibus Budget Reconciliation Act (OBRA) of 1987, Public Law No.

100-203. This Act contains many of the recommendations proposed in a 1986 Institute of Medicine report that Congress had directed the Department of Health and Human Services to commission. OBRA 1987 amended the Social Security Act, Titles 18 (Medicare) and 19 (Medicaid), to require substantial upgrading in nursing home quality and enforcement. To implement this legislation, the Department of Health and Human Services (DHHS) published regulations in 1989, 42 Code of Federal Regulations Part 483.

These regulations were substantially updated on October 4, 2016, at 81 Federal Register 68688-01. Violation of these regulations subjects nursing homes to a range of sanctions, up to decertification from participation in the Medicare and Medicaid programs.

During the national Public Health Emergency declaration issued in 2020 in response to the COVID-19 pandemic, DHHS temporarily waived a number of regulatory requirements that otherwise would bind nursing homes.

In a private civil lawsuit predicated on a theory of professional negligence, the plaintiff is required to establish four distinct elements by a preponderance of the evidence (a more likely than not standard) (Table 26- 1). First, the plaintiff has the burden of proving that the professional/provider defendant owed the patient an obligation defined by the appropriate standard of care. The existence of this duty ordinarily is established by showing that there existed, within the relevant timeframe, a professional relationship between the patient and provider; that is, the plaintiff was a patient of the provider for diagnostic and/or therapeutic purposes.

TABLE 26-1 ¦ ELEMENTS OF A PROFESSIONAL NEGLIGENCE CLAIM

Second, the plaintiff must present sufficient evidence that the professional/provider breached or violated the appropriate standard of care within the professional relationship. The professional/provider does not guarantee particular results, let alone perfection. By the same token, it is not enough for professionals/providers to “do their best” if their conduct does not rise to the applicable level of care, even when the errors or omissions were unintentional (ie, negligent). How the law determines the applicable level of professional care is discussed below.

The third element a medical malpractice plaintiff is required to prove is the occurrence of some financially compensable injury or damage. Besides special or economic (pecuniary) damages that include such quantifiable items as lost income and past and future health care–related costs, plaintiffs may be awarded general or noneconomic (nonpecuniary) damages for such difficult to quantify things as pain and suffering, mental anguish, grief, and other emotional complaints. In the past few decades, some juries have become more willing to award substantial noneconomic damages to older patients claiming medical negligence that has caused, for example, loss of function such as the ability to ambulate, drive, or toilet independently, chronic physical pain, diminution in mental capacity, or loss of ability to engage in sexual relations. In very rare circumstances, punitive or exemplary damages may be awarded over and above compensatory damages, where the defendant’s conduct has been not merely negligent, but reckless or malicious. For example, a jury might award punitive damages when it finds that a patient developed serious pressure ulcers because of a hospital’s or nursing home’s demonstrated ongoing pattern of neglect. Liability insurance policies purchased by health professionals (or purchased for them by their employers) ordinarily do not cover punitive damages.

The final component of proof in a professional malpractice lawsuit is the element of causation. To succeed, the plaintiff must persuade the jury, to a

reasonable (not absolute) degree of medical certainty, that the injuries were the result of the defendant’s negligence. The plaintiff must prove not only that the defendant’s negligence was a “substantial factor” in bringing about the injury or that “but for” (sine qua non) the defendant’s negligence the injury would not have happened, but further that there were no intervening, superceding (not reasonably foreseeable) forces that acted to break the chain of proximate or direct causation between the defendant’s negligence and the patient’s injury. For example, a physician might negligently fail to diagnose cancer in an older patient in a timely manner and the patient, on learning that cancer is at a stage that it cannot be treated effectively, commits suicide.

Assuming the availability of effective treatment if the cancer had been properly diagnosed in a timely manner, representatives of the deceased patient may argue that “but for” the physician’s negligence the death would not have taken place; however, the physician would respond that the patient’s act of committing suicide was an intervening, superceding (not reasonably foreseeable) factor that disrupted the chain of proximate causation between the physician’s negligence and the patient’s injury.

Legal standards of care have been established mainly by the courts as a matter of common law on an incremental, case-by-case basis. State statutes, such as those containing professional licensure requirements, also help to define the required standards of care.

Under the traditional formulation, a professional who is accused of negligent acts or omissions in a medical malpractice claim is held to a standard requiring the professional to have and exercise that level of knowledge and skill ordinarily possessed and exercised by competent, reasonable professional peers (in most states, determined on a national rather than local basis) in similar circumstances. Put differently, under long- standing tort principles of negligence, professionals have been judged legally according to the prevalent practice or custom of peer professionals in clinical circumstances like the situation that confronted the particular defendant in the case immediately before the court.

There is a significant trend in many states to evolve from the traditional customary professional standard of care in favor of imposing more objective, external standards of “reasonableness” against which the professional’s behavior is to be evaluated by the jury. An objective, evidence-based

standard of reasonableness may exceed (ie, require more knowledge and sophistication than) the prevailing customary practice within the professional community at the time in handling a specific clinical challenge presented by a patient. Thus, the state of the art in a particular area of care, required under a reasonableness standard, frequently might not be synonymous with and reflected in the current customary practice within the practitioner community. Courts adopting a reasonableness standard often recite the famous maxim of Judge Learned Hand: “Courts must in the end say what is required; there are precautions so imperative that even their universal disregard will not excuse their omission.”

When a reasonableness standard is imposed on malpractice defendants, expert witnesses may be allowed to testify, and thereby educate the lay jurors, regarding the appropriate professional conduct under the circumstances. To establish reasonable conduct, the parties may also introduce other kinds of evidence to supplement the testimony of the expert witnesses (Table 26-2). Additional forms of evidence introduced for this purpose may include professional codes of ethics, medical journal literature, textbooks (learned treatises), the Physician’s Desk Reference (PDR) and pharmaceutical package inserts (PPIs) pertaining to the correct use and dosage of prescription drugs, pertinent statutes or regulations, voluntary accreditation standards such as those of the Joint Commission, and, of increasing importance, pertinent clinical practice guidelines (CPGs) or parameters.

TABLE 26-2 ¦ PROOF OF THE STANDARD OF REASONABLE CARE UNDER THE CIRCUMSTANCES

Leaders in health care delivery and financing acknowledge that a good deal of routine medical practice has long been predicated more on habit and inertia than on solid empirical evidence establishing clinical efficacy. Out of a concern about both wasteful resource usage and the quality of patient care, professional organizations and specialty societies, including the American Geriatrics Society and the Society for Post-Acute and Long-Term Care Medicine (AMDA), governmental agencies led by the federal Agency for Healthcare Research and Quality (AHRQ), and the Patient-Centered Outcomes Research Institute (PCORI), independent bodies such as the U.S. Preventive Services Task Force, and individual institutions and agencies in the United States and elsewhere have engaged in a concerted movement to develop, collect, and disseminate to practicing clinicians a variety of evidence-based CPGs or parameters to educate practitioners about whether particular diagnostic or therapeutic interventions have actually been demonstrated to produce desired health benefits for patients. The Institute of Medicine has defined CPGs as “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.” Deviations from relevant CPGs may be permissible in the case of particular patients, but the health professional should document the justification for such deviation.

In a related vein, the American Board of Internal Medicine Foundation and Consumer Reports have partnered in a Choosing Wisely initiative designed to encourage and enable patients and physicians to share in making decisions about medical care that is supported by available evidence, not duplicative of other tests or procedures already received, and necessary for

that particular patient. Numerous medical specialty organizations have joined in this initiative, identifying common practices in their respective specialties for which physicians and patients ought to ask questions about the value obtained from routine use.

The legal ramifications of CPGs or parameters continue to evolve. Nevertheless, there is a growing tendency for the courts to admit into evidence, on behalf of either side to a malpractice dispute (ie, for either inculpatory or exculpatory purposes), properly validated, scientifically supported contemporary practice parameters on the issue of the standard of care to be applied under any particular set of circumstances. This development already has consequences, in that informal surveys show that plaintiffs’ attorneys consider health professionals’ compliance with or deviation from relevant practice parameters in making decisions about whether to initiate malpractice litigation at all and how to conduct settlement negotiations for claims that are pursued.

Because of added strains and resource limitations experienced by health care providers due to the COVID-19 pandemic, at least a dozen states enacted legislation providing immunity for providers shielding them against certain kinds of COVID-19-related liability claims. Congress has considered but not passed national legislation in this area.

Informed consent is the legal component of a broad modern shared decision- making approach that puts health care professionals in the role of decision facilitators or guiders rather than decision makers. The informed consent doctrine originates with the ethical principle of autonomy or self- determination, especially regarding the physical integrity and dignity of one’s own body.

A health professional/provider may be held civilly liable, usually under a negligence theory but in rare cases under a battery or intentional tort theory, for subjecting a person to any diagnostic, therapeutic, or research-related intervention without that person’s effective consent. In their legal formulation, the substantive parts of the informed consent rule have evolved over time as a function of state common (judge-made) law. Moreover, the majority of states have enacted statutes and regulations spelling out a

jurisdiction’s specific details regarding informed consent, for clinical care generally and/or within particular settings such as nursing homes or public mental institutions.

For a patient’s decision about whether to accept or reject a suggested medical intervention to be considered legally valid, three separate but interrelated elements must be present (Table 26-3).

TABLE 26-3 ¦ ELEMENTS OF LEGALLY VALID MEDICAL DECISION-MAKING

First, the patient’s participation in the decision-making process and final decision(s) regarding intervention must be voluntary, not unduly dictated by force, fraud, duress, or any other actual or perceived ulterior form of constraint or coercion. Second, the patient’s agreement or disagreement with recommended interventions must be properly informed. The professional is obligated to disclose sufficient information about the proposed intervention to empower the patient to make a knowledgeable, intelligent consent or refusal. The third essential element of legally effective medical decision- making is adequate capacity on the part of the patient to cognitively and emotionally understand and manipulate pertinent information about medical matters.

In terms of the informed component of informed consent, there are two competing standards for determining how much information about a proposed

medical intervention must be shared with the patient in advance. The medical custom or reasonable professional standard requires the disclosure of information that an objective reasonable, prudent professional would disclose under similar circumstances. By comparison, the materiality or patient orientation standard compels the sharing of information that might make a difference or be material in the decision-making process of a reasonable patient in similar circumstances. The states are approximately evenly split between these two competing standards of information disclosure.

Under either, the materiality or the reasonable professional standard, the basic components of information disclosure implicated by the professional’s fiduciary or trust obligations include the following: diagnosis or nature of the patient’s medical problem; nature and purposes (expected benefits) of the proposed interventions; reasonably foreseeable risks associated with the intervention, specifically, the likelihood of a risk materializing and the severity if it does occur; reasonable alternative interventions and their anticipated risks and benefits; and the reasonably foreseeable risks and benefits of not undergoing the proposed intervention. Other informational items that a health professional should seriously consider disclosing to the patient are complementary medicine alternatives, which are increasingly popular with older individuals; cost ramifications to the patient of proposed alternatives; professional-specific information pertinent to the particular intervention (eg, the professional’s own track record with the particular intervention or financial incentives the professional has regarding the patient’s course of care); and the level of uncertainty within the medical community concerning the particular intervention.

Informed consent to a medical intervention may be implied or expressed. There are many situations in which a patient’s permission to proceed with a medical intervention does not need to be put into words but, instead, may be implied from the context. This happens when, through demonstrative actions, the patient indicates a wish (or at least willingness) to undergo a specific intervention by voluntarily submitting to it in a manner that the health professional can reasonably rely on to conclude that the intervention has been authorized. Implied consent is appropriate for most routine, noninvasive,

non-risky kinds of medical interventions such as taking a patient’s blood pressure or listening to the heart. Implied consent is not an exception to the

informed consent requirement, but just a different (created by behavior instead of words) form of permission.

Express consent (put into spoken or written words), by contrast, is more appropriate when the proposed medical intervention is intrusive and/or significantly more risky than ordinary, everyday life. With a small number of exceptions created by particular state statutes for designated kinds of interventions (such as testing for the HIV virus), express consent in the form of spoken rather than written patient words is legally adequate, as long as the consent is voluntarily and competently given on the basis of sufficient information being disclosed. However, for particularly intrusive or risky interventions, the professional/provider should consider documenting the patient’s decision to consent or refuse by asking the patient to sign a separate written form, in addition to the professional making a progress note in the patient’s medical record. Also, voluntary accreditation standards with which the provider purports to comply, such as those of the Joint Commission, may require the use of separate written consent forms for particular sorts of medical interventions.

Sometimes, a patient is not cognitively and/or emotionally capable of assimilating pertinent information and engaging in a rational, voluntary decision-making process about proposed and alternative medical interventions. Some older persons with dementia, depression, or other age- related mental disorders are so impaired that they fall into this category.

When the patient personally lacks adequate decisional capacity, the health professional is not relieved of the duty to obtain informed consent but, instead, must work with someone else who is willing to act as a surrogate on the patient’s behalf.

Assessing decisional capacity entails a functional inquiry. Among the basic questions to be posed are (Table 26-4): (1) Can the person make and communicate in an understandable form any decisions at all? (2) Is the person able to offer reasons for the choices made, indicating some degree of reflection and consideration? (3) Are the reasons given based on logical reasoning proceeding from factually accurate suppositions? (4) Can the patient appreciate the ramifications (ie, likely risks and benefits) of the options outlined and choices expressed, and the reality that these

ramifications apply to that patient? (5) Does the individual comprehend the practical implications of different choices?

TABLE 26-4 ¦ COMPONENTS OF FUNCTIONAL ASSESSMENT OF DECISIONAL CAPACITY

A patient’s present cognitive and emotional capacity should be evaluated on a decision-specific, rather than a global or all-or-nothing, basis. A patient may be capable of making some kinds of decisions, but not others; partial or limited capacity, especially with adequate assistance and support by family or friends, is possible even when total capacity is not. Moreover, capacity may fluctuate within a specific patient according to variables such as time of day, day of the week, physical location, acute and transient physical problems, other persons available to support or coerce the patient’s choice, and medication reactions. Older individuals may be especially vulnerable to fluctuations in capacity induced by these factors. Some of these factors may be susceptible to manipulation by caregivers (eg, by changing timing of drug administration) so that discussions with the patient (rather than or in addition to the surrogate) about the care plan can take place under the most lucid circumstances possible.

Advance Health Care Planning as Prospective Decision-Making There are several legal mechanisms available to maximize a patient’s

medical autonomy prospectively. An older person may, while still capable of making health care decisions, execute certain legal instruments to anticipate and prepare for eventual incapacity by voluntarily delegating or directing the exercise of future medical decision-making power. Although oral advance medical directives are theoretically legally valid, patients should be encouraged to execute written versions to maximize the likelihood that the directive ultimately will be respected by family members and health

professionals. Organizational providers are required by the federal Patient Self-Determination Act to initiate discussions with competent patients about the availability of advance medical directive opportunities.

The durable power of attorney (DPA) consists of a written document in which an individual (the principal) appoints an agent, or attorney-in-fact, to make various kinds of decisions for the principal. Each state has enacted statutes that explicitly authorize the use of a DPA for health care (DPAHC) to empower an agent (including a nonfamily member) to make medical choices on a patient’s behalf, should the patient later lose decision-making capacity. Examples of DPAHC templates for individual states are available on the internet. A DPAHC may be immediate, meaning that it comes into effect as soon as the agent is named. In a springing DPAHC, on the other hand, the legal authority transfers (springs) from the patient to the agent only on the occurrence of some specified future event, like a declaration of the principal’s incapacity by a designated number of examining physicians. The patient should be informed by attending health professionals when they have decided to act as though decision-making authority has sprung to the designated agent, so that the patient can utter a protest, if desired, to the agent’s exercise of power.

The DPAHC is a proxy directive, and hence distinguishable from a living will or instruction-type directive. In an instruction directive, a competent patient documents his or her wishes regarding future medical treatment (eg, “no extraordinary measures” or “keep me alive forever no matter what pain or expense”) rather than naming an agent to make future treatment decisions in the case of eventual incapacity. The two kinds of legal devices are not mutually exclusive; indeed, patients may be encouraged to execute them in tandem because the living will can help an agent named under a DPAHC to exercise the patient’s substituted judgment (defined below) more accurately.

has not previously executed an instruction or proxy directive, in most states health professionals may rely on legislation empowering family members and enumerated other persons to make medical decisions for incapacitated persons. In states with such family consent statutes, the approved procedure usually consists of documenting unanimous agreement among the attending physician, specified relatives or others (listed in a stated preference order), and sometimes consultant physicians as well.

When there is no valid proxy or instruction directive, family consent statute, or judicial precedent in one’s jurisdiction authorizing the family to act as patient surrogate, or in those relatively uncommon situations in which family members strongly and irreconcilably disagree about the best course of care for their relative, judicial creation of a guardianship or conservatorship (nomenclature varies by jurisdiction) may be advisable to transfer decision-making power formally from an incapacitated patient to a single, specific surrogate. However, the official legal process (ordinarily entailing significant financial, time consumption, and emotional costs) should not be initiated unless and until less formal approaches, such as mediation or consultation with an institutional ethics committee or ethics consultation service, have been exhausted in an effort to reach a sufficient level of agreement among the interested stakeholders. In a guardianship/conservatorship case, professionals who have evaluated and/or treated the alleged incompetent person usually are called to provide evidence to the court in the form of a written affidavit and/or live sworn testimony. Many jurisdictions have public or volunteer guardianship programs that operate to provide surrogate decision makers for individuals with substantially impaired cognitive and/or emotional capacity who have no suitable family members or other private parties who can serve as guardians for them.

the guardian’s view, as a trust agent, of the patient’s best interests. The modern approach, however, is toward a substituted judgment standard of proxy decision-making, whenever it is realistically feasible. Under this latter approach, the surrogate is obligated to make those decisions that the patient would make, according to the patient’s own preferences and values to the extent these can be accurately ascertained, if the patient were presently able to make and express decisions competently.

Another innovation in advance health care planning is the Physician Orders for Life-Sustaining Treatment (POLST) paradigm (also known as Portable Medical Orders; see https://polst.org/). The precise title for this concept varies among jurisdictions. In some states, it is named Medical Orders for Life-Sustaining Treatment (MOLST; see https://molst.org/) and has also been named Physician Orders for Scope of Treatment (POST; see https://www.indianapost.org/). POLST is a mechanism to convert a patient’s treatment wishes into the tangible form of a written physician’s order.

Because health professionals are accustomed to carrying out medical orders, there is evidence that when treatment instructions are expressed in the form of a POLST they are substantially more likely to be honored in practice than are wishes expressed only in the form of a patient’s prior expression or a surrogate’s current representation of the patient’s inferred preferences.

Unlike an advance directive, a POLST is appropriate only for a patient who is so seriously ill that a physician exercising sound judgment would not be surprised if that patient died within the next year or two. Individual states are at different points concerning the degree of POLST penetration in medical practice and statutory and/or regulatory codification. There are no laws in the United States that prohibit either physicians from writing a POLST today for an appropriate patient or emergency medical services (EMS) or other health professionals from following a POLST.

While providing care, health professionals routinely are exposed to private information about patients and their families. Professionals owe patients a fiduciary responsibility to hold in confidence all sensitive patient information entrusted to them as a consequence of the professional/patient relationship. This ethical obligation, predicated on the patient’s important interest in protecting personal privacy and avoiding the social stigma and potential discrimination that breach of one’s medical privacy might entail, is enforceable legally under both state and federal law.

Every state, both within its state professional Practice Acts and in separate statutes pertaining to particular health care delivery settings, has enacted provisions pertaining to the confidentiality duties of health care professionals, institutions, and agencies. Often, state agencies publish accompanying regulations to implement these statutes. Moreover, a strong common law health care confidentiality doctrine has been forged by state court decisions rendered over time. Violation of state common law or the relevant statutory or regulatory requirements regarding confidentiality of patient information may subject erring health professionals/providers to civil damage suits, brought by or on behalf of the patient whose privacy was improperly infringed; additionally, violation of state Practice Act provisions

may subject the violator to administrative sanctions, including license suspension or even revocation.

However, numerous exceptions to the general confidentiality rule have been recognized by the courts as part of the common law or embedded in state legislation or regulation (Table 26-5). First, the most prominent exception occurs when a patient, expressly or impliedly, voluntarily and knowingly waives, or gives up, the right to assert the confidentiality of particular information. These waivers take place daily to make information available to third-party payers (for instance, Medicare claims processors and private health insurers), quality of care auditors (such as Joint Commission surveyors), and other public and private entities like health care surrogates authorized to make medical decisions on behalf of a patient who is not capable of making their own decisions. Because the modern delivery of health care is a team endeavor, each patient implicitly gives permission for the sharing of certain otherwise private pieces of information among the members of the treatment team. Internal information sharing of this nature is essential to optimal care, especially for accomplishing coordination and continuity of long-term care for older patients with disabilities. Indeed, failures in communication among the multiple providers involved in the care of a patient needing such coordination and continuity may form the basis for negligence liability claims when harm results.

TABLE 26-5 ¦ EXCEPTIONS TO THE DUTY OF CONFIDENTIALITY

Second, the usual confidentiality duty may be outweighed in situations of jeopardy to innocent, at-risk third parties, such as happens when a patient with serious sensory or cognitive impairments insists on continuing to drive an automobile or maintain loaded firearms in the home for protection against intruders. Particular details regarding methods for the health professional to

discharge the responsibility to report a credible threat of harm to public health or law enforcement authorities vary on the basis of state statutory and case law.

Third, the patient’s reasonable expectation of privacy must give way when the health professional is mandated by state statute to report to enumerated public health or law enforcement authorities (eg, Adult Protective Services [APS]) the professional’s reasonable suspicion that certain conditions or activities have occurred or are occurring. Such reportable conditions or activities may include elder mistreatment or neglect (in many states including cases of self-neglect is also within that definition), domestic violence, infectious diseases, and births and deaths. Some states that have declined to mandate the reporting of particular situations to public authorities nonetheless encourage voluntary reporting; a few states have pursued this approach regarding cases of suspected elder abuse or neglect.

Those states supply an incentive for voluntary reporting by expressly providing legal immunity against civil or administrative liability for covered persons making good faith reports to public authorities. Mandatory and voluntary reporting statutes embody the state’s exercise of either its inherent police power to protect and promote the general health, safety, welfare, and morals of the community or its parens patriae power to step up and safeguard individuals (such as persons with serious cognitive or emotional disabilities) who are not capable of protecting themselves. Further, a health professional may be compelled to reveal otherwise confidential information about particular patients by the force of legal process, namely, by a judge’s issuance of a court order requiring such release. This is a possibility in any civil or criminal lawsuit involving a factual dispute about a patient’s physical or mental condition. A court order (as opposed to a subpoena or subpoena duces tecum, which is issued simply as an administrative, nondiscretionary matter by the court clerk rather than by a judge) requiring one to produce personally identifiable patient information may override the state’s provider/patient testimonial privilege statute that ordinarily prohibits the provider from testifying in a legal proceeding regarding private patient information. Every state testimonial privilege statute provides for judicially compelled testimony on the part of the health professional when, for example, the patient has placed his or her own health condition and medical treatment in issue in a lawsuit. This could occur when, for instance, the

individual challenges the allegations propounded by others about one’s mental impairments made in a guardianship/conservatorship petition.

Particular health care se ttings There are a variety of federal statutes and regulations imposing on health providers particular confidentiality obligations when care is provided within specific types of health care settings, including federal penal institutions, Veterans Affairs facilities, military institutions, federal community health centers, and facilities specializing in the treatment of persons having drug and alcohol addiction. Violation of these laws may result in substantial civil fines. Statutes and regulations setting the conditions for receipt of Medicare and Medicaid payments contain confidentiality provisions, set within general patients’ rights standards, applicable specifically to nursing homes and home health agencies. Noncompliance with those provisions could trigger a range of regulatory sanctions, at the extreme including decertification of the facility or agency from participation in federal health care financing programs.

Health Insurance Portability and Accountability Act Federal regulations at 45 Code of Federal Regulations Parts 160 and 164 implement the Health Insurance Portability and Accountability Act (HIPAA) of 1996 (Public Law No. 104- 191, title XI, Part C). These regulations, published as a Privacy Rule and a Security Rule, impose on covered health care entities (defined in part as health providers who transmit identifiable patient information electronically) an extensive set of requirements regarding the handling of personally identifiable medical information contained in patient records. These regulations impose severe criminal and civil sanctions for unauthorized disclosures of personal health information. Substantively, HIPAA and its implementing regulations in essence codify preexisting state statutory and common law protections for patients, with the addition of provisions making it clear that patients have the right to access the information contained in their own medical records. (Previously, state law varied or was unclear regarding the issue of patient access to records.) Patient access to their own electronic medical records was expanded further in 2020, through the 21st Century Cures Act, to include clinical notes.

HIPAA contains provisions authorizing covered entities to transmit personal health information to certain others for purposes of “treatment, payment, and health care operations” such as quality assurance or marketing.

These and other exceptions explicitly contained in HIPAA basically track the preexisting state statutory and common law exceptions discussed in the previous section.

Individual health professionals and organizational providers serving older patients inevitably and continuously interact with laws and the legal system. This chapter has outlined a handful of the arenas in which this interaction is likely to occur. For advice in particular circumstances, especially pertaining to relevant state law, specialized legal consultation should be sought from knowledgeable attorneys in private practice, counsel and/or risk managers employed or retained by the health provider, the professional’s or provider’s liability insurance carrier, or an institutional ethics committee.

Blease C, Walker J, DesRoches CM, Delbanco T. New U.S. law mandates access to clinical notes: implications for patients and clinicians. Ann Intern Med. 2021;174(1): 101–102.

Bookman K, Zane RD. Surviving a medical malpractice lawsuit. Emerg Med Clin N Am. 2020;38(2):539–548.

Cohen AB, Costello DM, O’Leary JR, Fried RT. Older adults without desired surrogates in a nationally representative sample. J Am Geriatr Soc. 2021;69(1):114–121.

Comer AR, Slaven JE, Montz A, et al. Nontraditional surrogate decisionmakers for hospitalized older adults. Med Care.

Cooke BK, Worsham E, Reisfield GM. The elusive standard of care. J Am Acad Psychiatry Law. 2017;45(3):358–364.

Dillon E, Chuang J, Gupta A, et al. Provider perspectives on advance care planning documentation in the electronic health record: the experience of primary care providers and specialists using advance health-care

directives and physician orders for life-sustaining treatment. Am J Hosp Palliat Care. 2017;34(10):918–924.

Frolik LA, Kaplan RL. Elder Law in a Nutshell. 7th ed. St. Paul, MN: West Academic Publishing; 2019.

Glaser J, Nouri S, Fernandez A, et al. Interventions to improve patient comprehension in informed consent for medical and surgical procedures: an updated systematic review. Med Decision Making. 2020;40(2):119– 143.

Grosso S. What is reasonable and what can be proved as reasonable: reflections on the role of evidence-based medicine and clinical practice guidelines in medical negligence claims. Ann Health Law.

Hooper S, Sabatino CP, Sudore RL. Improving medical-legal advance care planning. J Pain Symptom Manage. 2020;60(2):487–494.

Jacobsen J, Blinderman D, Cole CA, Jackson V. “I’d recommend…”—How to incorporate your recommendation into shared decision making for patients with serious illness. J Pain Symptom Manage.

Jain N, Bernacki RE. Goals of care conversations in critical illness: a practical guide. Med Clin N Am. 2020;104(3):375–389.

Lee RY, Modes ME, Sathitratanacheewin S, et al. Conflicting orders in physician orders for life-sustaining treatment forms. J Am Geriatr Soc. 2020;68(12):2903–2908.

Mack DS, Dosa D. Improving advanced care planning through physician orders for life-sustaining treatment (POLST) expansion across the United States: lessons learned from state-based developments. Am J Hosp Palliat Care. 2020;37(1):19–26.

Oza VM, El-Dika S, Adams MA. Reaching safe harbor: legal implications of clinical practice guidelines. Clin Gastroenterol Hepatol.

Pope TM, Bennett J, Carson SS, et al., on behalf of the American Thoracic Society and American Geriatrics Society. Making medical treatment decisions for unrepresented patients in the ICU. Am J Respir Crit Care Med. 2020;201(10):1182–1192.

Schoenfeld EM, Mader S, Houghton C, et al. The effect of shared decision- making on patients’ likelihood of filing a complaint or lawsuit: a simulation study. Ann Emerg Med. 2019;74(1):126–136.

Shen MJ, Manna R, Banerjee SC, et al. Incorporating shared decision making into communication with older adults with cancer and their caregivers: development and evaluation of a geriatric shared decision-making communication skills training module. Patient Educ Couns.

Sulmasy LS, Bledsoe TA, for the ACP Ethics, Professionalism and Human Rights Committee. American College of Physicians Ethics Manual, 7th ed. Ann Intern Med. 2019;170 (Suppl.):S1–S32.

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Surgery in the older adult is different because of the increased risks of poor outcomes with seemingly simple or “routine” procedures but also because it can be challenging to identify those risks. Older adults preparing for surgery represent an incredibly diverse group of individuals not only because of the many available types and approaches to delivering surgical therapy but also because of the underlying vulnerabilities. Even though it is widely acknowledged that older adults are a heterogeneous group of patients they are also a distinctly vulnerable group of surgical patients who overall, experience disproportionately higher rates of postoperative complications, morbidity, and mortality. Thus, it is imperative to fully weigh the anticipated benefits of surgical interventions to the risks and explore whether this aligns with each patient’s preferences, their goals for the surgery, and overall health goals.

Identifying a person’s true baseline before surgery in terms of functional status as well as cognitive abilities can help more accurately assess an older individual’s tolerance of surgical stressors, which in turn allows for more realistic goal setting, permits sufficient time for presurgical optimization and prehabilitation, and enables planning for recovery if additional resources

need to be lined up. Examples of this frequently include friends or family traveling from out of town or requesting leave from work, an older adult temporarily moving to a friend or child’s home, or being a participant in choosing a postacute care facility that would be potentially acceptable if they needed more assistance and therapy during recovery.

Key Clinical Points

Older adults are a distinctly vulnerable group of surgical patients and need to be evaluated for high-risk characteristics including, advanced age, impaired cognition, dependency in functioning, impaired mobility, malnutrition, dysphagia, and discordance of goals for surgical outcomes.
Thoughtful use of screening tools increases discrimination for assessing surgical risk in older adults, but the use can be challenging because predictive validity and feasibility is widely varied with different instruments.
Person-centered care for older adults delivered using evidence- based interventions is done more efficiently and effectively using structured processes that include interdisciplinary teams engaged throughout the continuum of surgical care.

Over 16% of the US population is older than 65 years and roughly 10,000 adults turn 65 years of age each day. Longitudinal studies show as aging continues so do increases in chronic medical conditions, mobility limitations, widowhood, loneliness, and institutionalization. Older adults are

at increased risk of cognitive and functional decline. Those older than 85 years are even more likely to have accumulated age-related physiologic declines, leading to increased comorbidity, decreased functional abilities, decreased cognition, and malnutrition. These conditions create an increased vulnerability or frailty, which is an important predictor of adverse surgical outcomes. The cohort of high-risk older adults being considered for surgical therapy is going to be a sizable because by 2050, 20 million Americans will be 85 years or older. Despite increased physiological vulnerabilities, the demand for surgery will likely remain strong because subjective well-being remains positive over the course of old age and often surgeons use a communication strategy in which the surgical intervention is presented as restoring normalcy known as the “fix-it” model that may not fully explain the value of a planned surgical intervention and how it may impact someone’s lifestyle.

Nearly 40% of all surgical procedures are performed on older adults. Major surgery is a very common occurrence in the lives of adults older than 65 years. The 5-year cumulative risk for those in the United States is 14% (95% confidence interval [CI], 12.2%–15.5%) and remains relatively high even for those 90 years or older, 12% (95% CI, 9.9%–14.4%). Table 27-1 (data in bold) shows that half of the top 10 procedures performed in the United States are to address musculoskeletal disorders, which are frequently related to degenerative changes of aging. More importantly the deconditioning and decreased mobility from degenerative musculoskeletal disorders and potentially inappropriate medications to treat symptoms are directly related to increased risk of poor postsurgical outcomes, increased postoperative complications, and prolonged recovery after surgery.

TABLE 27-1 ¦ TOP 10 OPERATING ROOM PROCEDURES IN THE US

There are many individual markers or observable characteristics that can be used when assessing an older adult’s fitness for surgery either as discrete or composite measures. Recognizing these as geriatric-specific risk factors for poor surgical outcomes is important so that the risks can be anticipated and thus a plan put into place for appropriate shared decision making and risk mitigation.

Age over 80 years: How do we prognosticate? Advanced age should not be considered as the primary risk factor for predicting poor surgical outcomes because cognitive and physical abilities do not uniformly decline

as we age. Physiologic reserve also differs significantly between older adults as well as between major organ systems within individuals. Thus, age alone cannot be used to estimate surgical risk because of the increasing heterogeneity in older age. Despite this variance, older age is associated with a greater burden of chronic diseases and when we assess outcomes for the older cohorts of older adults there is a greater risk for adverse outcomes. When the outcomes for major noncardiac surgery are examined in patients older than 80 years for morbidity and mortality, those with who experienced any postoperative complication had a higher 30-day all-cause mortality than those who did not have any complications (26% vs 4%, p < 0.001). Thirty- day all-cause mortality has also shown to be higher in those older than 80 years after cardiac surgery. Age is the bluntest tool we have for assessing risk in older adults and it can remind us to be more aware of screening for a true baseline in physical and cognitive functioning, but it should not be the sole factor in the decision to proceed or not with surgical therapy.

Frailty: The oldest of old patients are more likely to be frail, which is a clinical syndrome characterized by low physiological reserve leading to increased vulnerability. Frailty can be a thought of as a general descriptive term or a defined geriatric syndrome with measurable traits with many different instruments to assess this in a clinical setting. The features observed with Fried’s phenotypic frailty are unintentional weight loss, weakness, exhaustion, low physical activity, and slow walking speed. Preoperative frailty in older adults is known to be associated with increased incidence of adverse postoperative outcomes, including more postoperative complications, increased length of hospital stay, and greater likelihood of being discharged to a skilled nursing or assisted-living facility. Because of the many available frailty scales, it is important to understand the strengths and weaknesses of the differing scales used. The phenotypic frailty scale is more often used for research and strongly associated with the development of postoperative delirium, whereas the Edmonton Frail Scale was a better predictor of complications, and the Clinical Frailty Scale tends to be more strongly associated with mortality and for discharge locations other than directly back to home. Acceptability, implementation, and feasibility are potential barriers to the use of frailty scales but selected use of these instruments can improve risk assessment particularly when used in combination with other risk-assessment tools. Table 27-2 reviews some of the more common scales mainly used during assessments preceding elective

TABLE 27-2 ¦ SELECTED FRAILTY SCALES USED IN SURGICAL RISK ESTIMATION

Gait speed: Gait speed is a direct or indirect component of many frailty scales, and slower gait speeds are associated with poor health and reduced ability to function. This single measure used during preoperative evaluation before cardiac surgeries is an independent predictor for increased in- hospital mortality, major complications, and discharge to a health care facility. As there are multiple factors that impact walking abilities, gait speed should be used to refine estimates of surgical risk and to identify those who may need more in-depth presurgical evaluation.

Weight and muscle mass: Weight loss is reflective of poor nutrition and/or poor utilization of nutrition, and in older adults is associated with many negative outcomes including loss of lean body and bone mass, development of pressure sores, slow wound healing, increased risk of infection, longer length of hospitalization, greater likelihood of hospital readmission after discharge, and increased mortality. Significant age- and disease-related reductions in skeletal muscle mass (sarcopenia) decrease the capacity of the older patient to make a functional recovery, possibly resulting in a discharge to a subacute or long-term care facility. Furthermore, weight loss preceding surgery increases the likelihood of delirium and postoperative pulmonary complications. All older adults need to be screened for nutritional risk before surgery because approximately one-third of older adults living in the community are at risk of being malnourished or are malnourished. This prevalence increases to a staggering 86% for those hospitalized. When an older adult has lost more than 10% of their body weight in the 6 months leading up to surgery or more than 5% in 1 month prior, further nutritional

screening and assessment should be done to develop a nutritional support plan based on the nature, extent, and underlying causes of the malnourishment. The Mini Nutritional Assessment (MNA) is one well- established and validated nutritional screening tool in older persons. Obese older adults should also be screened because they are more likely to experience postsurgical complications. Furthermore, the comorbidities most related to obesity such as diabetes, coronary heart disease (CHD), congestive heart failure (CHF), atrial fibrillation (A-fib), stroke, cancer, and arthritis also increase the risks of postsurgical complications and can contribute to slower recoveries after surgical therapy. See Chapter 49 for more discussion of sarcopenia.

Functional status and falls: Accurate assessment of functional abilities for managing day-to-day affairs of maintaining a household (IADLs) and performing self-care (ADLs) as adults age into advanced age provides important information about cognitive and physical limitations, available social supports, need for adaptive interventions, and the impact of their illness and risks for postoperative complications. Dependency in just one ADL (toileting, feeding, dressing, grooming, transferring, or bathing) prior to surgery has been shown to be associated with 75% greater odds of postoperative death compared to a matched cohort of functionally independent older adults. When examined in older adults undergoing elective colorectal or cardiac surgery, falling only one time in the 6-month period before surgery is another discrete factor associated with having at least one postoperative complication, an increased 30-day readmission rate, and higher risk of being discharged to an institution. A positive inquiry about falling should trigger further assessment for high-risk medication use, sensory impairments, neuromuscular limitations, cognitive deficits, mood disturbances, or environmental barriers. The ACS NSQIP©/AGS Best Practice Guidelines recommends evaluating function using the four-question Short Simple Screening Test for Functional Assessment:

If an older adult being considered for surgery cannot perform any of these activities, then a full inquiry should be performed about ADLs and IADLs to identify areas that need to be addressed both before and after surgery. Please see Chapter 43 for more about falls.

Cognition: Cognitive impairment, dementia, or history of prior delirium are significant risk factors for developing delirium following surgery. When dementia-level cognitive impairment is present before surgery as measured by the Mini-Cog screening tool, older adults are more likely to have increased complications, longer length of stay, higher discharge rates to institutional facilities, and long-term mortality as measured up to 4.5 years after a major elective surgery. Too often patients with cognitive impairment and dementia are excluded from clinical trials, thus there is limited literature on cognitive impairment as an independent risk factor for other postoperative complications. Nevertheless, delirium is the most common postsurgical complications for older adults and results in a sequalae of events that lead to increased likelihood of other complications including falls, aspiration, prolonged hospital stay, functional and cognitive decline, institutionalization, and death. Furthermore, postsurgical outcomes in older adults are worse when delirium occurs compared to postsurgical outcomes without delirium. This leads to an enormous loss of personal independence and financial burden with the 1-year direct cost of delirium in the United States estimated to be $33 billion. Therefore, it is critical to have a screening protocol in place to have a better understanding of an older adult’s cognitive abilities prior to surgery with more in-depth assessment for those who do not do as well as expected on the cognitive screening or for those with previously unrecognized cognitive impairment. When neurocognitive deficits are recognized, it then becomes important to allow for anticipated surgical risks and benefits to be presented in the most meaningful way for the patient and discussed in context of what is that person’s overall health goals and with the input of any surrogate decision makers. Please see Chapter 9 for more on cognitive assessment.

Depression and mood: Identification of mental health disorders including depression, anxiety, posttraumatic stress disorder (PTSD), and substance abuse disorders should be deliberately explored as part of preoperative geriatric risk screening. Older patients who present with depressive symptoms before surgery have a greater risk of experiencing postoperative delirium and longer postoperative hospital lengths of stay. Anxiety is also

associated with increased lengths of stay, and PTSD is associated with risk for emergence delirium (ED), which is defined as fearful, aggressive, and agitated behaviors that occur immediately following surgery upon awakening from anesthetic agents. Alcohol dependence may be overlooked in older adults but should also be screened for because it is associated with increased risk of postoperative complications.

The recognition of any mental health disorder should trigger scrutiny for actual use of prescribed medications including benzodiazepines, opioids, alcohol, illicit substances, and over-the-counter medications. Anticipatory guidance should include education/reassurance for the surgical procedure and plans for anesthesia and hospital and posthospital management of pain. Nonpharmacologic management should include exercise as tolerated, deep breathing, cognitive behavioral techniques for stress reduction, or integrated approaches such as music, aromatherapy, or massage. See Chapter 65 for more on depression and mood disorders.

Cardiopulmonary fitness: Poor cardiorespiratory fitness is the most significant independent predictor for postoperative mortality and length of hospital stay over age alone. Age-associated changes in cardiac physiology illustrate how age increases operative risk. This is primarily a result of a loss of vascular compliance, the left ventricle demonstrates an increase in stiffness, impaired diastolic relaxation, and an increase in filling pressures. These changes subsequently make the ventricle less tolerant of shifts in intravascular volume. An acute increase in volume (eg, from intravenous fluids administered during surgery) leads to a further increase in left ventricular filling pressures and could result in pulmonary congestion as a consequence of the age-related increase in diastolic stiffness. Conversely, an acute loss of intravascular volume, such as the third spacing of fluid or intraoperative blood loss, reduces preload to the stiffened ventricle and could produce a marked reduction in systolic blood pressure. Coronary artery disease (CAD), a common comorbidity, also increases risk; adding the intraoperative burden of myocardial ischemia to the already impaired diastolic relaxation leads to a further worsening of ventricular filling pressures and increases the risk of pulmonary edema.

When cardiac risk measures such as the Society of Thoracic Surgery and EuroScore II cardiac surgery risk models are added to frailty measures, the results are better model discrimination for postoperative outcomes.

Cardiac complications: CAD and heart failure (HF) are highly prevalent in older populations and remain the primary cause of death for the older patient. An estimated 25% to 30% of all perioperative deaths are attributed to cardiac causes. Because older adults are more likely to have significant CAD and HF, patients should be carefully screened for signs and symptoms of occult or overt disease. The left ventricular ejection fraction (LVEF) is an independent risk factor for major adverse cardiac events (MACE) with an increased risk of death when the LVEF falls below 40%. The risk of MACE is also higher among patients with HF with preserved LVEF than those without HF. Two-thirds of older adults with HF have normal left ventricular systolic function, and as previously noted the age-associated increases in vascular and left ventricular stiffness result in a greater sensitivity to volume shifts. Age-related declines in the electrical conduction system place the older patient at a greater risk of drug-induced bradycardia or high-grade atrioventricular blocks. A history of prior myocardial infarction or a low LVEF is associated with a greater risk of ventricular tachycardia. Older age (> 65 years) is also an independent risk factor for perioperative stroke and a history of stroke is a predictor of perioperative MACE.

Review Table 27-3 for age-related physiological changes by organ system and the relationship to postoperative outcomes.

TABLE 27-3 ¦ PHYSIOLOGIC CHANGES OF AGING AND EFFECTS ON PERIOPERATIVE CARE

In summary, because normal aging does not account for the bulk of operative risk, the clinician’s task is to identify underlying illnesses in older

Postoperative pulmonary complications are another important cause of postoperative morbidity and mortality. Besides patient-related risk factors such as cigarette smoking and history of chronic lung disease, advanced age is an important predictor of adverse postoperative pulmonary complications. With increasing age, the respiratory system demonstrates several changes in function, which may include a loss of pulmonary elastic recoil, decreased diffusion capacity, and reduced cough and gag reflexes, as a consequence of either neurologic injury or respiratory muscle weakness. Postoperatively, it is common for older patients to experience atelectasis or aspiration. An estimated 14% of older patients will have a major pulmonary perioperative complication (atelectasis, pneumonia, respiratory failure, exacerbation of chronic lung disease, bronchospasm, pleural effusion, pneumothorax, and airway obstruction), particularly after an abdominal or a cardiothoracic procedure. Postoperative pneumonia in older patients is associated with a 15% to 20% mortality rate. A detailed pulmonary and occupational exposure history prior to surgery can help predict impaired respiratory function.

Because neurologic events that may impair airway protection are occasionally subtle, obtaining a history of swallowing difficulties or prior aspiration may prompt postoperative interventions aimed at reducing aspiration risk.

Renal function is reduced as a result of glomerular and tubular senescence. The progressive sclerosis of glomeruli that occurs with increasing age is hastened by comorbid conditions such as hypertension, diabetes mellitus, and CAD. In the older patient, the serum creatinine often does not fully reflect the reduction in renal function. The age-associated reduction in skeletal muscle reduces creatinine production, so a reduced creatinine clearance is not always as apparent, even in the setting of diminished filtration. Baseline renal insufficiency results in greater risk for volume and acid-base disturbances in the perioperative period. Older adults are more susceptible to preoperative dehydration, intraoperative fluid shifts, hypotension, and hypovolemia, factors associated with the development of acute tubular

necrosis, the most frequent cause of postoperative renal dysfunction. Certain medications and use of contrast dye can also contribute to renal toxicity.

Also, alterations in renal (and hepatic) metabolism place the older patient at a greater risk of perioperative drug toxicities.

Postoperative infectious complications represent a major source of morbidity and mortality for older adults. In addition, the development of a surgical site infection or other health care–acquired infection can substantially increase length of stay and associated health care costs. The extended use of indwelling devices, prolonged ventilation, and length of stay are important risk factors for postoperative infections. Infections associated with devices and prosthetic material can present unique treatment challenges. The treatment of significant infections often requires extended courses of parenteral and/or oral antimicrobial therapy, which can raise issues related to safety and tolerability of antimicrobial agents, including nephrotoxicity.

Prolonged need for antimicrobials can also increase the risk of Clostridium difficile infection. Prevention strategies are evolving and include targeted preoperative decolonization for Staphylococcus aureus.

While emergency surgeries are associated with a higher overall death rate in all age groups, this finding is most apparent among older patients who have the highest mortality rates as a consequence of a greater number of complications. The causes for the increased risk are multifactorial. The identical surgical disease in the older adult may present later in its course, and diagnosis can be delayed because of an atypical presentation. Also, the older patient may undergo surgery later due to efforts to “optimize” comorbidities prior to surgery. In the older patient, a delay in a needed nonemergent surgery may have a greater risk if the delay could result in an emergent procedure. Therefore, clinicians should be aware that if the time needed to optimize the patient for surgery is extended, an anticipated elective procedure could become a higher-risk emergent procedure.

A neurologic event, such as a stroke, may increase the risk of aspiration by impairing the ability to swallow, to move food through the esophagus, and to

control respiratory secretions. Advancing age is also associated with a decrease in esophageal peristaltic wave amplitude, reduced tone of the lower esophageal sphincter, a greater incidence of hiatal hernias, delayed gastric emptying, and increased gastroesophageal reflux, all of which are factors that may increase the perioperative aspiration risk. Impaired glucose regulation and risk for stress hyperglycemia are common in this age group and may increase infection risks. Thus, careful monitoring to control blood sugars perioperatively may have important benefits. Pressure injuries are another important postoperative complication (see Chapter 46 “Pressure Injuries”). Age-related changes in mobility and sensation can contribute to breakdown of skin integrity. Aggressive preventative measures including frequent assessment and pressure unloading are essential aspects of postoperative management.

Taking the time to thoroughly discuss what is involved with a particular surgery with older patients and their families can help promote a clearer understanding of risk and benefits and reduce false expectations.

Incorporating regular patient and family conferences can be helpful. In such discussions, it is often apparent that an older patient has a different outlook and acceptance of a specific level of care. Shorter-term goals, such as the quality, not quantity, of life may be most important. Additionally, the overall tolerance of surgery may be different than that of a younger person. The understanding that a longer time to recover may be necessary is often best communicated in this forum. It is also important to inform the patient and family that an intermediate-care program may be needed, such as a subacute care center, a rehabilitation unit, as well as the extended use of home care services.

Anesthesia is generally considered a safe procedure in older patients, with a progressive decline in complication rates being observed in recent years.

Preoperative risk factors are a better predictor of 7-day mortality than is the duration of anesthesia or the experience of the anesthesiologist. Once the preoperative risk factors are controlled for, the type of anesthesia (eg, spinal vs general) fails to predict outcomes. The greatest period of risk for complications remains the time immediately after surgery, with half of adverse events occurring within 3 weeks of surgery.

Limited social support is also a risk factor. Among orthopedic patients, those with adequate social support are doing better 6 months after surgery.

Cancer adds a unique challenge for older adults going for surgery because they may require chemotherapy or radiation therapy before their surgical intervention; they may go into surgery with worse health status compared to prior to cancer diagnosis. Cancer also adds psychological stressors because uncertainties related to their condition add anxiety, increasing the risk for delirium and poor outcomes.

A systematic way to organize the complex factors that older adult bring to surgical decision making and planning is essential in order to provide care that aligns both with the technical capabilities of the surgery and the goals for the patient in pursing surgical therapy.

Older adults may have very different goals for their surgery, so it is very important to have a shared decision-making process during the perioperative assessment and planning for older adults. All available data should be gathered, including clear direction from the surgeon about surgical goals and outcomes, as well as risk related to differing surgical techniques. Planning for a potential ostomy is an example where sometimes patients may not fully understand the chances of this outcome or the required lifestyle modifications unless it is explicitly addressed. It is also recommended to have someone accompany the patient during their clinic visits because their friends and family may want to discuss the surgical goals, overall health goals, preoperative preparation, and planning for recovery in more detail after the clinic visit.

Preoperative clinics should leverage community resources, family members, and an interdisciplinary team to address and optimize perioperative risk factors unique to older adults, in accordance with best practices.

The older patient may be unable to adequately communicate concerns or clinical history to a health care provider. Therefore, maximizing the communication and exchange of data between the surgical team and the medical providers can help ensure the best possible outcome for the older patient. Clinical programs that foster close communication among surgeons

and consulting internists or geriatricians have demonstrated improved surgical outcomes and greater functional recoveries. Teamwork and communication between the various services are critical to promoting the best possible understanding of the patient’s clinical situation, helping to mitigate surgical risk.

ACS NSQIP©/AGS Best Practice Guidelines: The American College of Surgeons (ACS) with the American Geriatrics Society (AGS) provided evidence-based guides for best practices approach to identify risk and focus on prevention in preoperative assessment of older adults undergoing surgery (Table 27-4). These best practices create a framework for engaging older patients and their caregivers to create a patient-centered approach that guides every member of the interdisciplinary and interprofessional team caring for the older adult. The integration and coordination of care in the older surgical patient undergoing elective surgery begins when the surgery is scheduled.

is delivered, representing the best chance to improve surgical care for an aging population. Structured perioperative care around evidence-based best practices improves the quality of care, reduces unnecessary hospital admissions, reduces hospital acquired complications, while providing a patient-centered approach by eliciting individual goals and preferences for each patient. If the decision is to pursue surgery, this approach creates the opportunity for collaboration across different settings of health care delivery during the entire continuum of surgical need, until full recovery.

TABLE 27-4 ¦ ACS NSQIP ®/AGS BEST PRACTICE GUIDELINES FOR OPTIMAL PERIOPERATIVE MANAGEMENT OF THE GERIATRIC SURGICAL PATIENT

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Geriatric 5 Ms: Age-friendly health systems are recognizing four or five evidence-based elements of high-quality care that organize the complexities of assessing the surgical risks and surgical planning for an older adult into a framework organized by: What Matters Most, Mentation, Mobility, Medication, and Multimorbidity/Multicomplexity.

Interdisciplinary teams: Preoperative clinics should leverage community resources, family members, and an interdisciplinary team to address and optimize perioperative risk factors unique to older adults, in accordance with best practices. Many of the clinical care points in

recognizing and mitigating surgical risk can be acted upon by many members from a variety of professions. Interestingly, the Clinical Frailty Scale is valid for use by health care professionals with a license or registration for example MD, RN, LPN, OT, PT, SW, or psychologist.

Comprehensive geriatric assessment: This would be the “gold standard” means to use multidimensional, interdisciplinary, interprofessional process and teams to fully assess in a complete manner an older adult’s medical, psychological, and functional status within their social and environmental circumstances. This information allows for a patient-centered plan to manage and treat their surgical needs beginning with optimizing targeted areas before surgery and creating an integrated plan for treatment during hospitalization and throughout recovery.

Postoperative management includes the appropriate use of medications for pain, increasing mobilization, proper use of urinary catheters, the treatment and prevention of delirium, and anticoagulation use.

Pain control: Pain is often undertreated in older patients because of the concern of using potent analgesics in older patients and a misconception that pain sensations are diminished in such patients. Postoperative patients should be regularly asked about the severity of their discomfort using analog scales, and analgesics should be given according to anticipated needs rather than “as needed.” Simply scheduling pain medications is another useful approach.

Comments on the management of persistent pain, medication dosing, and metabolism, as well as associated toxicities, are well summarized by the AGS comprehensive review of this topic. See Chapter 68 for more detail about pain management.

Early mobilization: Prolonged bed rest can adversely affect the older patient. Changes noted with prolonged immobility include a decrease in cardiac output and aerobic capacity, baroreceptor desensitization and orthostatic hypotension, skeletal muscle deconditioning, bone loss, hypercalcemia, joint contractures, constipation, incontinence, pressure sores, sensory deprivation, an increased risk for deep vein thrombosis (DVT), atelectasis, hypoxemia, and pneumonia. Early mobilization from bed is vital, helping to reduce the risk for complications. If the recovery process prevents full mobilization, then a physical therapy referral for range-of-motion

exercises and the maintenance of an upright posture (chair) may reduce the frequency and severity of these complications.

Catheters: Postoperative urinary drainage is often managed by an indwelling catheter but this predisposes to urinary tract infection and associated complications. Catheter use should be short, with a goal of prompt removal by the morning after surgery. If there is a concern for urinary retention or bladder distension, then intermittent catheterization should be considered. The use of a urinary catheter beyond 48 hours should be avoided, except when retention cannot be managed by other means. Patients requiring long-term use of a urinary catheter should not be given prophylactic antimicrobials.

Postoperative delirium: An acute confusional state occurs in 10% to 15% of older patients undergoing general surgery, 30% of cardiac surgery patients, and, in one study, up to 50% of hip fracture repairs. Delirium is also a marker for worse functional recovery, and older patients with in-hospital delirium are at risk of significant long-term reduction in cognitive function (see Chapter 58 on delirium).

Delirium is often subtle and can easily be missed. Clinical factors key to the diagnosis are a rapid onset, a disturbed level of consciousness, decreased attention and environmental awareness, memory deficits, disorientation, perceptual disturbances, and evidence of a condition that contributes to its development. A history of dementia as well as prior delirium, advanced age, and a prior decline in cognitive function are risk factors for perioperative delirium. As a rule, delirium fluctuates and may not be evident during all visits. Nursing staff and family members are often the most reliable source for the serial assessments of an at-risk patient.

Delirium often compromises postoperative care and extends the length of stay. Behaviors can often be controlled with environmental measures, such as a bedside sitter, increased visitations by family, frequent orientation, minimizing abrupt relocations, and permitting patients to return to a more normal day-night cycle. If medically appropriate, the use of a sleep protocol is often helpful. Symptomatic control of agitation to prevent harm is occasionally needed. Unfortunately, no single drug has an accomplished record. High-potency antipsychotics such as risperidone, haloperidol, olanzapine, and quetiapine should be cautiously titrated to improve symptoms. Lower-potency drugs such as chlorpromazine and thioridazine should be avoided because of their associated anticholinergic and

arrhythmogenic effects. If delirium is secondary to alcohol withdrawal, short-acting benzodiazepines can be used with close monitoring for excessive sedation. Formal delirium prevention protocols can be helpful, especially in the intensive care unit setting.

Other complications: Postoperative surveillance for myocardial ischemia, infarction, arrhythmias, and DVT should ideally lead to a reduction in mortality. Postoperative myocardial ischemia is the strongest predictor of cardiac morbidity. Anginal pain may be masked by narcotics or may be difficult to verbalize during recovery. Postoperative ST-segment changes on electrocardiogram (ECG) are indicative of myocardial ischemia and are an independent predictor of events. Such changes are associated with a worse long-term survival. The optimal surveillance strategy for the diagnosis of postoperative ischemia or infarction has not been defined. In patients without documented CAD, surveillance should be restricted to patients who develop signs or symptoms of cardiovascular dysfunction. Cardiac troponin measurements should be part of the diagnostic plan for myocardial infarction detection, but additional research is needed to correlate outcomes to the magnitude of an isolated cardiac troponin elevation. As a rule, postoperative myocardial infarctions have a similar pathology to infarction occurring in a nonsurgical patient, the spontaneous thrombosis of the coronary artery.

Therefore, when this complication occurs, appropriate medical management as well as an aggressive attempt at opening the infarct-related artery should be considered in the appropriate postoperative patient.

Postoperative arrhythmias are often caused by correctable noncardiac problems such as infection, hypotension, metabolic abnormalities (hypokalemia and hypomagnesemia), and hypoxia. Ventricular arrhythmias (frequent ventricular ectopic beats or nonsustained ventricular tachycardia) may occur in more than one-third of high-risk patients. Prophylactic use of antiarrhythmics other than ß-blockers is not recommended. Sustained ventricular tachycardia with or without hemodynamic complications requires consultation with a cardiologist. Postoperative A-fib is common.

Approximately 25% of older patients develop this rhythm. Age and the type of surgery are strong predictors for the development of A-fib. The prophylactic use of a ß-blocker and amiodarone has shown some benefit by reducing the frequency of this rhythm, but is not routinely recommended.

Hemoglobin levels often fall after major surgery. Transfusions should be reserved for patients with symptoms and possibly those with levels below 7

g/dL. Small trials have demonstrated that administering intravenous iron infusions in anemic patients prior to hip and knee replacement surgery reduced the need for postoperative blood product transfusions.

Cognitive decline has been noted following a variety of surgeries. The International Study of Postoperative Cognitive Dysfunction found that 26% of patients older than 60 years who had either intra-abdominal or orthopedic procedures had a significant decline in cognitive function 1 week after surgery. Risk factors included older age, greater use of anesthetics, and postoperative respiratory and infectious complications. In coronary artery bypass surgery, where the aorta is often cross-clamped and a bypass pump is used, embolization of both gas and particulates occurs. As a result, central nervous system ischemic damage is often noted after these procedures.

Postoperative cerebral infarcts (many subclinical) are the likely cause of cognitive decline noted with cardiac surgery. Off-pump coronary artery bypass surgery seems to have a lower rate of short-term decline in cognitive function (21% vs 29%), but similar decline is noted at 6 months (31% vs 38%). The risk of further decline in cognitive function should be incorporated into the decision process for patients with underlying dementia who are not undergoing emergent or lifesaving surgery. Finally, postoperative critical pathways involving regimens, including low-dose opiates, early extubation, and an emphasis on accelerated functional recovery, can be safely applied to older patients.

The management of anticoagulants prior to surgery is briefly summarized. For patients on chronic warfarin with an international normalized ratio (INR) goal of 2.0 to 3.0, four scheduled doses should be withheld to allow the INR to normalize to less than 1.5 before surgery. If the INR is typically kept above 3.0, then longer periods without a warfarin dose may be required. The INR should be measured on the day of surgery to ensure that it has reached an acceptable range. If the INR is excessive, a small dose of vitamin K (eg, 1 mg intravenously or 2.5 mg orally) may be given, which will further reverse the INR within 24 hours. If rapid reversal of the INR is required, fresh frozen plasma can be administered. When the INR is less than 2.0, other prophylactic antithrombotic interventions should be considered.

Elective surgery is best avoided for at least 3 months following a DVT or pulmonary embolism (PE) event to ensure adequate duration of anticoagulation treatment. If this is not possible, then anticoagulation bridging with low-molecular-weight heparin (LMWH) should be given before and

after the procedure for patients on warfarin while the INR is less than 2.0. LMWH should be stopped 24 hours before surgery; restarting LMWH can be considered 24 to 48 hours after surgery, depending on the type of surgery, bleeding risk, and thrombotic risk of the patient. Patients receiving one of the newer oral anticoagulants (eg, dabigatran, rivaroxaban, or apixaban) do not require perioperative bridging therapy given the relatively short half-life of these agents. These medications can be discontinued 1 to 4 days prior to surgery depending on the patient’s risk of thrombosis, surgical bleeding risk, and renal function.

As our society ages, the need for surgical procedures will continue to increase among older adults. Age alone is not a reliable predictor of operative risk and should not be the sole criteria for deciding who should and who should not have surgery. However, age is associated with a higher prevalence of chronic diseases, which, in turn, are strong predictors of operative risk and help determine who might benefit from surgery and preoperative testing. The AHA and ACC have published updated guidelines, which help guide preoperative cardiac risk assessment. Perioperative care requires a careful medical evaluation and comprehensive postoperative observation that anticipates potential complications. Newer techniques related to minimally invasive surgery appear promising. Besides decreasing recovery time and postoperative pain, there is some suggestion that overall operative risk may be decreased. Future studies examining clinical outcomes of interest in older adults will be an essential component of evaluating the relative risks and benefits of new interventions.

Many thanks to Satyen S. Nichani, Paul J. Grant, and Preeti N. Malani for their contributions to the Perioperative Evaluation and Management components of this chapter in earlier editions of this book.

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Scarborough JE, Bennett KM, Englum BR, Pappas TN, Lagoo-Deenadayalan SA. The impact of functional dependency on outcomes after complex general and vascular surgery. Ann Surg. 2015;261(3):432–437.

By the year 2024, people 65 years and older will represent over a quarter of the global population. Soon, there will be more older people than children and more people at the extremes of old age than ever before. This trend in population aging will undoubtedly translate into increasing numbers of older adults in developed countries requiring invasive and minimally invasive procedures for revascularization (joint repair and replacement), urologic, and gynecologic-, gastrointestinal-, and ophthalmologic-related surgeries, and more. In the United States, for example, older adults already account for approximately 40% of all in-patient operations and about one-third of outpatient procedures performed annually. One of the major challenges of treating older patients is the heterogeneity of the geriatric population—and the need to individualize care for each patient to provide the best outcome.

As the incidence of comorbidity increases with age, so does the risk for postoperative complications and longer hospital stays which underscores the collaborative roles that geriatricians, anesthesiologists, and surgeons are certain to play, moving forward in the care of the older surgical patient.

Indeed, high quality care for older adults undergoing major and even minor surgical procedures requires a well thought-out and all-inclusive approach to risk stratification, communication, and coordination. Accordingly, in July 2019, the American College of Surgeons initiated the Geriatric Surgery Verification (GSV) Program that provides hospitals with a validated list of 30 evidence-based and patient-centered standards for geriatric surgery, which hospitals can implement to continuously optimize surgical care for this vulnerable population. These standards define the resources and processes

that hospitals need to have in place to perform operations effectively, efficiently, and safely in older adults (defined by 75 years and older), while also always prioritizing what matters most to individual patients with regard to their needs and treatment goals. At the time of composing this chapter, one hospital had achieved Level 1 verification of being a Geriatric Surgery Hospital, and 11 other institutions, among seven states, were at the “Commitment Level” of the verification process. Given the aging demographics and expected uptick in the need for surgical services in those 75 years and older, it is likely that all major medical centers will move in the direction of GSV certification. It is nearly certain that geriatricians will play key roles in the shared decision-making process and interdisciplinary approach to continuously optimize surgical care for older adults. In view of this, this chapter will provide the reader with a general understanding of: (1) intraoperative management strategies (eg, regional vs general anesthesia [GA] vs sedation) aimed to minimize risk of some of the common complications of older patients (eg, postoperative delirium [POD] and cognitive dysfunction); (2) special concerns attached to geriatric cardiac procedures performed within and outside the operating room (eg, hybrid cardiovascular and electrophysiology suites); and (3) perioperative issues that relate to Allow Natural Death (AND) orders.

documented, including verification of the “time” the modification is in place.

The decision as to which kind of anesthesia that will be used is dependent on several factors including the patient’s medical history, the surgical procedure that is to be performed, the preference of the surgeon and anesthesiologist, and the patient’s first choice. As the primary goal is to provide the safest anesthetic with the best outcome possible, the anesthesiologist, who is the perioperative medicine expert, will thoroughly explain the options to the patient and surrogate while also discussing the rationale for recommending one over another method. The types of anesthesia that might be used include general anesthesia, regional (peripheral nerve blocks) or neuraxial anesthesia (eg, spinal or epidural), combined general and regional anesthesia, and conscious sedation (Figure 28-1). When either general or neuraxial anesthesia is deemed appropriate for an older adult, for instance in the case of hip fracture repair, neuraxial is often the preferred choice. With all anesthesia modalities, the patient’s breathing, oxygenation, heart rate, blood pressure (BP), and body temperature are closely monitored

intraoperatively and in the postanesthesia care unit. To appreciate the latest medical literature on how anesthetic type might influence the most common postoperative complications among older adults undergoing surgery and anesthesia, a basic understanding of the different techniques available and the anesthetic agents used to ensure safe outcomes is warranted.

FIGURE 28-1 Schematic displaying the types of anesthetic techniques for older patients requiring surgery and minimally invasive procedures in and outside the operating room. MAC, monitored anesthesia care; TAP, transverse abdominal plane.

To begin with, GA is the state produced when a patient receives medications for amnesia, analgesia, muscle relaxation, and sedation. An anesthetized patient is considered being in a state of controlled, reversible unconsciousness. General anesthetics, in the form of inhalational (eg, isoflurane, sevoflurane, desflurane, nitrous oxide, and xenon) and/or intravenous agents (eg, propofol, ketamine, and etomidate) depress the central nervous system to a sufficient degree to permit the performance of surgery and other noxious or unpleasant procedures. To control breathing, the anesthesia care provider inserts either an endotracheal tube or a laryngeal

mask airway into the trachea or pharynx, respectively, after the patient is rendered unconscious following induction of anesthesia. Maintenance anesthesia is commonly provided with volatile or inhalational anesthetics, which offer reliable control over the depth of anesthesia. Short-acting opioids (eg, fentanyl, sufentanil, or alfentanil) are used for analgesia along with the inhalational agent, because the latter has only weak analgesic properties. To facilitate endotracheal intubation and minimize the need for high-dose volatile anesthetics, neuromuscular blocking agents (eg, succinylcholine, rocuronium, vecuronium, or cisatracurium) are often used. Table 28-1 shows the commonly used intravenous drugs, their side effects/contraindications, and dosing concerns/recommendations for the older patient. Standard monitoring, including pulse oximetry, electrocardiogram (ECG), noninvasive BP device, temperature monitor, measurement of end-tidal carbon dioxide, inspired oxygen concentration, and low oxygen concentration and ventilator disconnect alarms are employed in all older adults undergoing a general anesthetic. A peripheral nerve stimulator is also used to guide dosing of short-acting neuromuscular blocking agents and to ensure complete reversal of neuromuscular blockade, if extubation is planned at the end of the surgical procedure. Indeed, even a small amount of leftover neuromuscular blockade can have profound effects on pharyngeal muscle function, predisposing the older patient to aspiration pneumonia. As older adults are more sensitive to intravenous anesthetics, volatile agents, and opiates due to age-related changes in pharmacokinetics and pharmacodynamics, anesthetic dosing is age-adjusted and anesthetic depth continuously monitored by end-tidal anesthetic concentrations and

physical signs. Because many of the assumptions about anesthetic depth might not be as reliable in the older adult as they are in younger patients, brain function monitoring with processed electroencephalography (pEEG) or a bispectral index (BIS) monitor is often used. Limiting excessive anesthetic depth while avoiding awareness and recall after surgery in older patients, is a key tenet of the American Society of Anesthesiologist’s Brain Health Initiative. Not only is this important for mitigating neurotoxicity and the potential for perioperative neurocognitive dysfunction, but it also reduces the risk of acute kidney injury, adverse cardiac events (eg, myocardial infarction [MI] or injury), and central nervous system ischemic events as a result of anesthetic-induced intraoperative hypotension. In general, BP is maintained within 20% of the patient’s baseline and mean arterial pressure (MAP) is

kept at 65 mm Hg or above (and systolic BP = 100 mm Hg). However, in older patients and particularly those with preexisting hypertension, target mean BPs are best kept well above 65 mm Hg. Indeed, increasing evidence in the anesthesia literature shows that even brief periods (eg, = 10 minutes) of perioperative hypotension (defined as systolic BP < 100 mm Hg or MAP

TABLE 28-1 ¦ COMMONLY USED INTRAVENOUS ANESTHETIC- RELATED DRUGS

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tion (lf"spbj??..::ttr c-.f Od:?:'li. ro11?tip:?,tio??; ????1?rit11s.;?1iL - clt ri,g,,dit,? (t.>g, rl??s? il) r1rln:11ry rcter.itlon.

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..:: ,8(1y,1\t?;tk iu <,,if(1a:ct, oo-??. tklt??r [?uri•?cting ?.g????[ (t1<g, r?nlf!!nl-:?.?ibl}v.l?l?. on?:roll!Ul delivery '}•?m.

Regional or neuraxial anesthesia is the injection of a local anesthetic around major nerves (eg, axillary, femoral, interscalene, and intercostal nerve blocks) or in the subarachnoid (spinal anesthesia) or epidural spaces

(epidural anesthesia), to block a limb and/or a large region of the body (eg, hip fracture repair). Regional anesthesia (RA) provides excellent muscle relaxation in addition to intraoperative and postoperative pain control, given that local anesthesia-induced blockade of sodium channels can last 8 to 12 hours, depending upon the dose, or employment of a catheter for continuous local anesthetic delivery for analgesia (eg, epidural catheter). Upon placement of the regional or neuraxial block, small, incremental doses of intravenous fentanyl or remifentanil might be given to help position the patient. Intraoperatively, low-dose propofol, or dexmedetomidine infusions, is oftentimes administered to provide conscious sedation, as needed. As RA has been linked to improved postoperative pain scores and patient satisfaction, reduced opioid consumption, and opioid-related side effects (eg, nausea, ileus, respiratory depression), it should be considered part of a multimodal pain-reducing approach (eg, surgical field infiltration with local anesthetics, utilization of peripheral nerve blocks, nonsteroidal anti- inflammatory agents, clonidine, and dexmedetomidine) whenever possible in older patients prone to developing postoperative respiratory depression.

It might seem intuitive to care providers that the procedure becomes “less intrusive” by choosing RA, and accordingly, leads to better outcomes.

Indeed, seeing patients back in their respective rooms, awake, oriented, eating, and conversing with family members after an orthopedic procedure implies a speedy and favorable recovery. However, the controversy persists as to whether RA is better than GA with respect to patient mortality and morbidity. For hip fracture repair, for example, the International Fragility Fracture Network recently shared no preference for or against general or neuraxial anesthesia, but rather stated that hospitals should follow their own local guidelines. In a 2018 systematic review and meta-analysis, no differences in 30-day mortality or serious events (eg, pneumonia, acute MI, renal failure, or delirium) were found for RA compared to GA for patients undergoing hip fracture surgery. Moreover, a retrospective cohort study by Neuman and colleagues published in 2014, involving over 56,000 patients 50 years or above undergoing hip repair surgery could not find a difference in 30-day mortality when RA was compared to GA, but did show that RA led to a modestly shorter length of hospital stay. Until the completion of two large- scale, multicenter, randomized controlled trials that are examining the efficacy of RA versus GA for hip fracture surgery in older individuals—the REGAIN trial with a primary endpoint of walking after 60 days and other

patients-centered outcomes up to 1 year postop, and the iHOPE trial with an endpoint of all-cause mortality or cardiac or pulmonary events within 30 days postoperatively—anesthesiologists base anesthetic modality choice on patient’s preferences, and the patient’s comorbid conditions and potential for postoperative complications.

Because many older adults are taking anticoagulant and antiplatelet medications for the prevention of stroke and thromboembolism, these patients are at a heightened risk for neuraxial bleeding and the development of an epidural hematoma. While this does not necessarily preclude the use of neuraxial techniques (eg, spinal or epidural), or paravertebral blocks, deep plexus blocks, and deep peripheral nerve blocks (eg, in anatomic locations not amenable to the application of pressure to control hemorrhage), it does require careful planning and communication among members of the patient’s perioperative care team, the patient’s primary physician, and the patient. The American Society of Regional Anesthesia and Pain Medicine 2018 consensus guidelines for patients receiving hemostatic altering medications provide anesthesiologists with information on timing of drug cessation prior to neuraxial techniques, bridging therapy in cases of warfarin usage, maintenance of neuraxial catheters, and timing for starting medications after a neuraxial technique or removal of the neuraxial catheter. For many of the newer medications, recommendations are based on elimination half-lives.

The mechanism of drug elimination and clearance is also taken into consideration as many of the antiplatelet drugs are renally metabolized and have prolonged action in those older patients with reduced renal function.

Monitored anesthesia care is the intravenous administration of short- acting sedatives, analgesics, and anxiolytics to help a patient relax during minor procedures (eg, colonoscopy, transesophageal echocardiogram, and interventional radiologic procedures) that do not require GA. This is sometimes referred to as conscious sedation. Because of the increased risk for postoperative neurocognitive dysfunction among older patients, benzodiazepine administration should be avoided and sedation and analgesia be achieved with propofol, ketamine, or dexmedetomidine. Because of the “fine line” between light and deep sedation in older individuals, all dosing of sedatives and analgesics are reduced, and the spontaneously breathing patient receiving supplemental oxygen is continuously monitored for respiratory rate, oxygen saturation, end-tidal carbon dioxide, in addition to all other standard ASA (American Society of Anesthesiologists) monitoring.

Changes in capnography values and waveforms often help clinicians understand a patient’s level of comfort, sedation, and respiratory function during procedural sedation. Indeed, if the patient is not communicative or unable to cooperate, reluctant to be awake, and/or if the procedure length is deemed to be longer than usual, GA might be a better choice to achieve the goal of a rapid recovery.

It is well accepted that older age is a risk factor for perioperative mortality and morbidity, including cardiovascular, pulmonary, renal, and neurocognitive complications. Of the postoperative complications, cognitive morbidity in the form of POD and persistent cognitive decline are significantly more prevalent when compared to any of the other complications (Table 28-2). Accordingly, this section will provide insight on the impact that anesthesia and surgery might have on the development of perioperative neurocognitive disorders (PND) and strategies that are used to help mitigate its occurrence. See Chapter 27, Perioperative Care: Evaluation and Management, for specifics on risk factor assessment for PND.

TABLE 28-2 ¦ POSTOPERATIVE COMPLICATIONS IN OLDER SURGICAL PATIENTS

In order to unify the neurocognitive disorders seen by anesthesiologists with the cognitive classifications observed in the general population based on the Diagnostic and Statistical Manual for Mental Disorders, fifth edition (DSM-5), the term “perioperative neurocognitive disorders” was established in 2018. This term encompasses patients presenting for surgery with preexisting neurocognitive disorders (eg, mild cognitive impairment and Alzheimer disease), and those with POD, delayed neurocognitive recovery (cognitive decline up to 30 days after surgery), and postoperative neurocognitive disorder (defined as a decline in cognition that persists or is diagnosed up to 12 months after the procedure). Delayed neurocognitive recovery and postoperative neurocognitive disorder align with mild cognitive impairment and dementia. In this chapter, postoperative cognitive dysfunction (POCD) and postoperative neurocognitive disorder are used interchangeably given that much of the literature to date has used the former term.

POD is a common and serious complication of anesthesia and surgical care. Unlike emergence delirium, which occurs immediately after emergence from anesthesia and resolves quickly, POD may show up a week after the procedure or even at the time of hospital discharge. It has severe consequences to the patient including increased risk of mortality, need for discharge to an institution, accelerated cognitive and functional decline, and an increased risk of falls. At the medical center level, POD associates with increased length of stay and higher readmission rates—both leading to increased costs. POD not only affects perioperative care, it takes a tremendous psychological toll on caregivers and the patient. While the surgical procedure might have gone flawlessly, the older patient might be referred to by his or her family as “just not the same.” For the patient, this can also be very isolating and contribute to posttraumatic stress disorder.

The occurrence of POD in older patients after noncardiac surgery in past studies has ranged between 5% and 52%. In a 2020 systemic review and meta-analysis involving 17,241 patients (35 studies) undergoing GA for noncardiac surgery, and 15,090 patients (19 studies) for cardiac surgery the pooled incidence of POD was 17% (95% confidence interval [CI]: 14%– 9.2%) and 15% (95% CI: 13%–18%), respectively. In another recent study involving over 20,000 surgical inpatients, people 65 years or older, the

unadjusted average rate of delirium occurrence across 30 institutions was 12%. By specialty, the highest rates of POD occurred for cardiothoracic (14%), orthopedic (13.0%), and general surgery (13.0%), and the lowest rates were associated with urologic (6.6%) and gynecologic procedures (4.7%). Multivariate analyses further indicate that patients at highest risk of POD are older, have more comorbidities (eg, higher ASA classification), more likely to have undergone emergent surgery, and more likely to have preexisting cognitive impairment. Indeed, many of the same patients who develop POD are also those who are frail. Frailty is common in older elective surgical populations; 38% to 54% of those greater than or equal to age 70 in one study scored as prefrail and 35% to 41% as frail on comprehensive frailty measures. Screening for frailty and cognitive impairment preoperatively using the FRAIL scale and the Animal Verbal Fluency test in older elective spine surgery patients identified those at high risk for the development of postoperative delirium. Accordingly, it is important to inform older patients who screen positively for preoperative frailty or cognitive impairment that their risk for developing POD is increased and their anesthesia care team will take a proactive approach to minimize this risk. Furthermore, educating family and caregivers as to what to look for postoperatively will help identify POD early, if it occurs.

Currently, there is limited evidence in support of one anesthetic modality over another to reduce POD. In a 2018 Cochrane database review, no differences with regard to safety and postoperative delirious symptoms were shown between total intravenous anesthesia (eg, propofol) versus use of volatile agents, including Xenon, in older patients undergoing noncardiac surgery. The effect of RA versus GA on delirium in hip fracture repair patients also remains inconclusive, in part because rigorous and adequately powered studies, to date, are lacking.

Adjunctive pharmacologic therapies have been examined for their benefit in reducing the occurrence of POD. The selective alpha-2 adrenergic receptor agonist dexmedetomidine is one such drug that has shown promise in reducing the risk of POD. In three meta-analyses conducted over the past several years, intraoperative infusions of dexmedetomidine were found to lower the incidence of POD in older non cardiac surgical patients, albeit with a potential increase in bradycardia. Unfortunately, there remains insufficient evidence for dexmedetomidine administration to have the same POD-reducing benefit in older cardiac surgery patients. Other adjuvants have

been tested with the goal of improving pain control without excessive need for opioids. Both gabapentin and ketamine have been studied in randomized controlled trials, but no role for these adjuvants in reducing the incidence of POD was reported.

Guiding anesthetic depth with pEEG monitoring has been considered in the armamentarium of anesthesiologists to help limit the risk of delirium in some older patients. As the BIS monitor produces a single number between 0 and 100, it is assumed that the lower the number, the deeper the anesthesia.

Titrating the dose of volatile or intravenous anesthesia to a BIS of 40 to 60 or 50 to 60 versus standard monitoring with end-tidal anesthetic concentration has been shown to reduce the rate of POD in four trials involving general anesthesia and in one study that randomized patients into receiving BIS target values of at least 80 (intervention) versus 50 (control) during sedation with propofol in spinal anesthesia. However, a large prospective trial entitled Electroencephalography Guidance of Anesthesia (ENGAGES) that randomized GA in adults (age > 60 years) undergoing major surgery (including cardiac, gastrointestinal, thoracic, gynecologic, hepatobiliary- pancreatic, urologic, and vascular procedures) to pEEG-guided or routine care found no difference in the incidence of delirium between groups (26% in the EEG group and 23% in usual care). Even so, favorable findings for brain depth monitoring for POD reduction in the ADAPT-2 trial (Anesthetic Depth and Postoperative Delirium Trial-2) suggests that cognitively vulnerable older patients may actually benefit from reducing time in burst suppression during the surgical procedure. While the existing data do not support routine use of pEEG monitoring for the prevention of POD in older patients, it remains a practical monitor to consider for those older adults who have preexisting PND, and when the goal is to facilitate rapid emergence and recovery.

In summary, except for possibly dexmedetomidine administration, none of the approaches (eg, intravenous vs inhalational anesthesia, regional vs general anesthesia, incorporation of processed EEG monitoring, use of adjuvants such a gabapentin or ketamine) have sufficient evidence to support their use in the reduction of POD in older patients. What we do have available are “best practice” consensus guidelines from various professional societies and working groups, including the American Geriatric Society (AGS), the American College of Surgeons (ACS) in conjunction with NSQIP, the European Society of Anesthesiology, the International Society

Perioperative Neurotoxicity working group, and the American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus. A summary of the recommendations by these expert panels is presented in Table 28-3. Notably, multicomponent, nonpharmaceutical interventions (eg, frequent orientation, reinstitution of dentures, hearing and vision aids, early mobilization, preservation of day/sleep cycles, staff education, adequate and frequent pain assessment, early removal of indwelling catheters, adequate hydration, and early reinstitution of nutrition) and avoidance of high-risk POD medications (eg, Beers Criteria) are recommended by nearly all groups in the management of modifiable risk factors for delirium.

TABLE 28-3 ¦ SUMMARY OF POD REDUCING RECOMMENDATIONS FROM CONSENSUS GUIDELINES AND EXPERT PANELS

Two questions may surface among older patients slated for a surgical procedure—“does POD lead to dementia?” and/or “will anesthesia and surgery provoke dementia?”—for which geriatricians should have some knowledge. With respect to the first question, findings from several earlier studies (2008–2017) suggest that POD may be a predictor of progression to dementia and cognitive decline years after surgery. For example, Inouye and colleagues in 2016 found nondelirious patients crossing the trajectory of

cognitive decline at 36 months when compared to their baseline cognitive status, whereas patients with POD crossed the trajectory to POCD at 12 months after surgery. However, more recent work suggests that delirium and cognitive dysfunction after surgery are independent and distinct entities. In a retrospective cohort study of 560 older noncardiac surgery patients, fewer than half of those who developed delirium (134 of 560 or 24%) went on to develop POCD at 1 month (47%), but this proportion dissipated after 2 (23%) and 6 months (16%), implying that POD and long-term POCD might be different disorders. The second question, “will cognitive function decline after surgery?” is justifiable. The association between exposure to anesthesia and surgery to long-term cognitive trajectory continues to be a topic of debate. Longitudinal data from a cohort of older adults (n = 1819) in the Mayo Clinic Study of Aging demonstrated a small decline in cognition in those who had undergone surgery versus those who had no exposure to anesthesia and surgery in the 20 years prior to their enrollment. Using participants from the Whitnall II cohort study, Krause et al reported modest reductions in cognition coincident with those who were admitted for major surgery, whereas a strong association with cognitive decline was found for those hospital admissions that were for medical only reasons. In a nationwide population-based cohort study from Korea involving nearly 45,000 patients (50 years and older) who required surgery, the hazard ratio for developing dementia over the 12-year study period was 1.28 after adjusting for covariates when compared to 175,000 age-matched controls.

Taken together, POD is likely not part of a continuum to POCD or long-term dementia, but rather a separate entity. People who experience POCD do not necessarily have POD first. Also, hospital stays for surgery are not linked to higher risks for PND than admissions for medical only reasons.

To ascertain whether the brain is “injured” by anesthesia, the association between exposure to GA versus RA and the risk of developing dementia has been considered. In a population-based propensity study involving 41,700 community-dwelling individuals 66 years or older who underwent one of five elective surgeries by GA or RA, Velkers and colleagues found, after matching 7500 patients in each group, no difference in the onset of dementia up to 5 years after surgery. Going one step further, the effects of sevoflurane GA without surgery, in 59 healthy volunteers between 40 and 80 years, was reported to have no adverse influence on plasma biomarkers of neurological injury or systemic inflammation. In fact, a minimum alveolar concentration

(MAC) of sevoflurane actually reduced plasma tau, neurofilament light (NF- L), and glial fibrillary acidic protein (GFAP) 5 hours after anesthesia when compared to respective baseline values.

As anesthesia alone does not appear to be a significant harbinger to the onset of dementia, others found that the extent of surgery has an impact on the development of neurocognitive decline. In a large data set from the Korean National Health Insurance Services, Choi et al identified nearly 64,000 patients with a diagnosis of gastric cancer who underwent curative gastrectomy surgery and compared them to 203,000 age-matched controls for onset of dementia. Interestingly, these investigators found no differences in dementia after surgery in the partial gastrectomy group but a 1.3-fold higher risk of dementia development in the total gastrectomy group when compared to controls. This finding points to the potential for a “dose response” effect of surgery on postoperative neurocognitive disorders, which should be considered when planning surgery in older patients.

Taken together, PNDs are common complications in older adults undergoing anesthesia and surgery which have serious consequences. The etiology underlying postoperative delirium, delayed cognitive recovery and/or postoperative cognitive decline remains poorly understood, and is unlikely a distinctive cause. In those who are at an increased risk for PND, for example, preexisting dementia, minimally invasive or less extensive procedures, or a surgery that might be linked to functional improvement (eg, cataract surgery), or one that associates with dementia risk reduction (eg, carotid endarterectomy, abdominal aortic aneurysm repair) should be considered. To date, no recommended intraoperative anesthetic technique or pharmaceutical PND prevention exists, but rather standardized therapeutic concepts in the perioperative period (eg, staff and patient education, early mobilization, good pain control and adequate pain assessments, maintenance of normothermia, avoiding excessive BP fluctuations, and avoiding benzodiazepines and anticholinergic medications) are being incorporated into hospital practice bundles and electronic medical record alert systems to help ensure safe and optimal outcomes in the geriatric surgical population.

Table 28-4 lists recommendations for the prevention and management of postoperative nausea and commonly used classes of other perioperative drugs that require caution with use or avoidance in older patients.

TABLE 28-4 ¦ PERIOPERATIVE MEDICAL MANAGEMENT AND PRECAUTIONS

Both structural and electrical cardiac diseases are common in patients over the age of 75. Structural cardiac disease includes coronary artery disease (CAD) and valvular pathology—particularly aortic stenosis and mitral regurgitation (MR). Among the electrical cardiac diseases regularly diagnosed in the older adult are atrial fibrillation (AF) and sinus node dysfunction. Procedures to treat these diseases are routinely performed in patients over the age of 75 years. While there is a tendency to prefer less invasive procedures in this patient population, correction of certain cardiac lesions requires GA with endotracheal intubation, invasive arterial pressure monitoring, and central venous access. The standard anesthetic for cardiac surgery in the older adult provides hemodynamic stability, amnesia, analgesia, end-organ protection, and the ability for rapid emergence postoperatively. Numerous studies have attempted to show advantages of

specific anesthetic drugs and adjuvants over others to achieve these goals but results remain equivocal.

Patients with significant cardiac disease, whether or not they are undergoing procedures to address their cardiac disease, often require specific monitoring beyond typical GA monitors described earlier in this chapter. In patients with reduced ventricular function or severe valvular disease, an arterial pressure monitor called an arterial line is often placed in one of the radial arteries prior to, or immediately after, induction of GA. Preinduction placement of an arterial line allows for the anesthesiologist to measure beat-to-beat arterial BP variations during anesthetic induction. As discussed earlier, induction of GA can lead to changes in BP because many of the agents used to induce and maintain GA cause peripheral vasodilation and hypotension. Patients with severe cardiac disease may not tolerate long periods of hypotension; while invasive pressure monitoring will not prevent or treat hypotension, it will allow the anesthesiologist to closely monitor BP and treat small changes more quickly than would be possible with a noninvasive BP monitoring system that measures only every few minutes.

Transesophageal echocardiography (TEE) allows for real-time monitoring of cardiac ventricular and valvular function. TEE is commonly performed after induction of GA and endotracheal intubation in patients undergoing cardiac surgery and sometimes in those with reduced systolic function or “tight” aortic stenosis who require noncardiac surgery. TEE is more invasive than transthoracic echocardiography (TTE), but TEE has the advantages of being performed by an anesthesiologist at the head of the bed without interfering with a sterile surgical field, and it provides significantly better image quality than TTE for most patients. Central venous access is typically obtained via the right internal jugular vein. An introducer placed in this vein can allow the anesthesiologist to place a pulmonary artery catheter in selected patients having cardiac surgery with cardiopulmonary bypass. Postprocedure, patients are typically transferred to the intensive care unit (ICU) for continued monitoring and mechanical ventilation. Specific considerations for selected cardiac diseases and associated interventions that require anesthesia are discussed further.

As patients age, the incidence of CAD increases. An estimated 30% of patients over the age of 75 have clinically significant coronary disease, compared with 8% of patients younger than 65 years. While many of these patients can be treated by a percutaneous intervention (PCI), certain lesions are best repaired surgically. Benefits of coronary artery bypass graft (CABG) surgery over PCI are less well-defined in patients 75 years and older than in those younger than 75 or middle-aged. Standard CABG surgery is performed under GA with invasive arterial pressure monitoring, endotracheal intubation, central venous line placement with or without a pulmonary arterial catheter. Adverse outcomes associated with CABG surgery include stroke, renal injury, and postoperative neurologic dysfunction. Studies show that older patients are more likely to have more severe disease, such as left main or multivessel CAD with concomitant left ventricular dysfunction. In combination with enhanced cardiac disease severity, decreased functional capacity, frailty, and cognitive impairment may lead to worse outcomes in this patient population when compared to their younger counterparts. Other risk factors widespread in this population, including smoking, obesity, diabetes, and hypertension, further contribute to less favorable outcomes than in younger cardiac surgical patients.

As an alternative to traditional CABG with cardiopulmonary bypass (CPB), certain surgeons will offer off-pump coronary artery bypass (OPCAB) surgery to patients with select lesions. OPCAB can be performed via a conventional sternotomy or a minimally invasive approach via a left thoracotomy. The minimally invasive approach may include a robotic surgical technique. The incision for minimally invasive OPCAB is smaller than a traditional sternotomy, but the pain score associated with the thoracotomy is often higher than that of a sternotomy. Surgery performed via a thoracotomy requires lung deflation on the surgical side. To achieve this, the anesthesiologist must selectively ventilate one lung while the surgeon is working. This approach may not be appropriate for patients with significant lung disease, as they may not tolerate one-lung ventilation. The benefit of OPCAB, regardless of the surgical approach, is the avoidance of CPB and its associated risks. OPCAB versus CABG has been extensively studied; however, no clear data, to date, demonstrate a significant advantage of one over the other in all-cause mortality, cardiac outcomes, or success of revascularization in the general population. Interestingly, some subgrouping analyses suggest improved outcomes of OPCAB over CABG in the geriatric

population. Indeed, OPCAB that avoids manipulation of the ascending aorta (eg, which is usually cross-clamped prior to the initiation of CPB in CABG surgery) may lead to improved neurologic outcomes. Some patients are best served by a hybrid approach that typically combines off-pump surgical revascularization for the left anterior descending artery with a PCI to repair other high-grade lesions. This staged approach allows for complete revascularization while limiting the time under GA.

Aortic stenosis is the most common single valve disease, with a prevalence between 2% and 10% in patients over age 75. Because senile calcific aortic stenosis increases with aging, procedures that replace the aortic valve are offered to patients in this age group. Indications for aortic valve replacement include severe aortic stenosis and symptomatic moderate aortic stenosis.

Aortic valve replacement can be performed in a variety of ways. The standard approach is via a midline sternotomy with CBP. Minimally invasive aortic valve replacement can be performed on CPB via an upper hemi- sternotomy or anterior thoracotomy. All three surgical approaches have a clinically equivalent 1.2% risk of stroke. As with OPCAB, thoracotomy approaches require lung isolation. An alternative to surgical valve replacement is a transcatheter aortic valve replacement (TAVR). While TAVR tends to be more commonly performed in the “middle- and oldest-old” (mean age of 83 years) age groups, improvements in technology and reductions in associated complication rates have expanded its potential to the “youngest-old” (65–74 years) and to those considered to be at low-risk.

TAVR is typically performed in a percutaneous manner via the femoral artery. The valve is delivered retrograde up the descending aorta and deployed without removing the patient’s native aortic valve. At some centers, TAVR is performed with GA and endotracheal intubation; at others, it is performed with a local anesthetic at the femoral puncture site along with varying levels of conscious sedation. Even for cases where sedation is planned, conversion to GA is not uncommon. Reasons for conversion to GA include the patient’s inability to cooperate by remaining motionless and/or inability to breathe comfortably while lying flat, or the proceduralist has a need for better imaging of the aortic valve—thereby necessitating placement of a transesophageal probe for TEE, or because of a procedural complication.

intravenous access. In patients who have significant distal aortic, iliac, or femoral arterial disease, transfemoral placement of the valve may not be possible. For these patients, surgical cutdown to one of the major arteries (femoral, axillary, carotid, or aortic) may be required for TAVR placement. Due to the discomfort associated with surgical cutdown, GA with endotracheal intubation is required. Patients who require intubation during the procedure are typically extubated at the end of the procedure, although due to the femoral vessel access, they must remain supine for several hours in order to reduce bleeding risk. Post TAVR, patients may not require ICU admission and are able to leave the hospital after 1 or 2 days, representing a lower level of required postoperative care compared with surgical aortic valve replacement. Even so, overall complication rates for TAVR are still as high as 20%; with stroke rates, significant postprocedure paravalvular leaks, and major bleeding accounting for 2%, 3.6%, and 6%, respectively.

MR is the most frequently acquired valvular heart disease in the United States; this may be due to the many underlying causes of MR. Up to 50% of patients with left ventricular dysfunction have some MR. The mitral valve can be repaired or replaced surgically utilizing CBP with GA, endotracheal intubation, invasive BP monitoring, and TEE. After addressing MR, the left ventricular afterload can be dramatically increased; patient selection for mitral valve intervention is important because some patients will not be able to tolerate this increased afterload. In the hands of an experienced surgeon, operative risks and recurrence of MR are low. Overall, surgical mortality is estimated at less than 2% in patients with an average age of 60 years. Newer technology for addressing MR is constantly being developed. There are several methods for decreasing MR including edge to edge repair techniques, annuloplasty bands to decrease the size of the valve, neochords, and percutaneous mitral valve replacement. The nonsurgical techniques for mitral valve repair are not as well established as those for treating aortic stenosis, and thus are reserved for patients who are a prohibitive surgical risk. As of 2020, only the MitraClip (Abbott) is Food and Drug Administration (FDA) approved in the United States. The MitraClip clasps the edges of the two leaflets together in both phases of the cardiac cycle to decrease regurgitation. This procedure requires GA, invasive arterial pressure monitoring, and TEE guidance. Patients are typically extubated at the end of the procedure,

although due to the large caliber venipuncture, they must remain supine for several hours in order to reduce bleeding risk. Patients who cannot tolerate the flat time, due to dyspnea or poor cooperation, may need to remain intubated with sedation during this recovery period.

AF is a common comorbidity in the geriatric population; the median age of patients with AF is 75 years. Incidence of AF increases with age and is 2.3% in people older than 40 years, 5.9% in those older than 65 years, and 10% in those older than 80. Patients with AF are anticoagulated to decrease the risk of stroke from embolization of left atrial clot; the proportion of strokes due to AF is likely greater than 20%. Due to the high prevalence of AF in this patient population and the increased risk of anticoagulation in older patients who are at increased risk of falls, AF ablation procedures are frequently performed in this group. Recurrence in AF is less than 50% after catheter- based ablation compared with 80% for those treated with antiarrhythmic medicines alone. AF ablation is typically a catheter-based procedure with access via the femoral vein. Anesthetic management includes GA with endotracheal intubation, possible TEE to assess for cardiac muscle paralysis, and arterial access. Arterial access is generally placed after anesthetic induction for monitoring of BP and heparinization. The patient must be heparinized during the procedure because the catheter crosses the interatrial septum into the left atrium to gain access to the pulmonary veins for ablation. As long as the catheter is in the left atrium, the patient must be anticoagulated to an activated clotting time (ACT) of 250 seconds in order to decrease risk of generation of thrombus that can cause harmful emboli.

Patients are typically extubated at the end of the procedure, although due to the large caliber venipuncture, they must remain supine for several hours in order to reduce bleeding risk. In patients for whom rhythm control cannot be achieved and anticoagulation is not tolerated, left atrial appendage occluder devices can be placed. Because 90% of left atrial thrombi are located in the left atrial appendage, these devices may decrease stroke risk in patients with AF who cannot tolerate anticoagulation. There are several commercially available devices, with both percutaneous and surgical techniques as options. The anesthetic requirement for these devices is similar to that of AF ablation, including GA, TEE, and often invasive arterial pressure monitoring for frequent blood draws to monitor the level of anticoagulation.

Implantation of cardiac rhythm devices is another frequently performed procedure in the geriatric population, since the largest risk factor for sinus node dysfunction is aging. Sinus node dysfunction is the most common indication for pacemaker placement, accounting for 50% of all implants in the United States. Anesthetic management is similar for all device placements. In many cases, device placement can be performed with sedation. In order for this to be successful, the patient must be able to cooperate and there must be adequate pain control. To ensure patient comfort during the procedure, the electrophysiologist performing the procedure must be able to give adequate local anesthetic to numb the insertion site and the pocket where the generator will be implanted. The patient must be able to stay still for the procedure and respond to directions in order to prevent vascular injury associated with patient movement. Some electrophysiologists prefer to perform the procedure under GA in order to avoid the potential discomfort of a sedated patient, both for the patient and the proceduralist. In addition to preference of the proceduralist, some patients may require GA with or without endotracheal intubation due to their inability to tolerate the procedure with sedation. This may be due to patient anxiety, airway obstruction due to sedation (ie, obstructive sleep apnea), or an inability of the patient to tolerate lying still due to pain or dyspnea.

As anesthesia for cardiac procedures and cardiac surgery require that the anesthesiologist possess much of the knowledge typically within the jurisdiction of the cardiologist and cardiac surgeon, in addition to having a proficient skillset in performing and interpreting TEE examinations, a fellowship-trained cardiac anesthesiologist will be leading the intraoperative management, in parallel with the surgical/proceduralist team and perfusionist, particularly when a CPB circuit is needed. There is no

doubt that older adults with cardiac disease, and the various clinicians caring for them, are faced with difficult and often multiple reasonable options.

Shared decision-making enables both the patient and clinician the ability to contribute their differing but equally important areas of expertise to find the best path toward the patient’s personal care goals. Having general knowledge of the anesthetic techniques involved in many of the more common cardiac surgery procedures will provide the geriatrician with a foundation of information that can aid in their contribution to the shared decision-making process.

Given that many people at the end of life have surgical procedures, the impact of Do Not Resuscitate and Allow Natural Death (AND) orders should not be ignored. In a medical beneficiary study from 2008 involving over 1.8 million older individuals, 32% underwent an inpatient surgical procedure during their last year before death, 18% underwent a procedure in their last month of life, and 8% underwent a surgery in their last week of life. In part because of these data, and the fact that it is becoming more common to encounter an older patient scheduled for surgery who has an AND in place, hospitals accredited by The Joint Commission are required to have an AND policy. Indeed, procedures requiring anesthesia can create an ethical dilemma when AND/Do Not Intubate/Limited Resuscitation orders are in place prior to a surgery because “resuscitation” is nearly always ongoing to some degree in the operating room while a patient is undergoing surgery with anesthesia. In the case of a patient with a documented AND, the four main tenets of health care ethics come to the forefront. First, the patient has the right to be informed and to make decisions regarding his/her care, particularly at the end of life. Automatic suspension of an AND constitutes betrayal of autonomy. Second, the procedure being offered must be of some benefit to the patient in either quantity or quality of life. Also, with respect to beneficence, patients do not have a right to a treatment that is not deemed to have a benefit. Certainly, nonmaleficence or “do no harm” underscores all aspects of medicine. Lastly, the principle of justice comes to play when health care providers offer resources (eg, surgical procedures) that are limited to those who will best benefit from them.

The American Society of Anesthesiologists state that physicians must communicate and document any modifications that are made to the patient’s wishes and advanced directives prior to surgery. This should be done with the patient while in the presence of both the surgeon and anesthesiologist.

Most often the patient’s wishes to hold the AND can be met under one of the following three categories: (1) full attempt at resuscitation within the perioperative period, (2) limited attempt at resuscitation defined in regard to specific procedures (eg, chest compression, intubation), and (3) limited attempt at resuscitation defined with respect to the patient’s goals and values. Importantly, automatic suspension of the AND is not acceptable and any modifications must be discussed with the patient and documented. These discussions require time and should be conducted well before the surgical

procedure and then readdressed immediately prior to surgery, with the patient and the lead perioperative team members present so that everyone is aligned with the plan and the patient’s wishes. Under the best circumstances these discussions should also include the primary care provider, nursing staff in the operating room/recovery room, and possibly a chaplain. It is important to reassure the patient and his/her family that having an AND order does not mean “do not treat.” In a retrospective analysis using the American College of Surgeons NSQIP database 2007–2013, 5000 patients with AND orders in place had, as expected, an increased incidence of mortality, however, there was no difference in morbidity at 30 days when compared to non-AND matched patients by procedure, and after adjusting for preoperative factors.

This tells us that patients received routine treatment for complications after surgery such as wound infection, renal failure, stroke, deep venous thrombosis, and pulmonary embolism but did not necessarily receive advanced cardiac life support. In summary, older patients are having procedures at the end of life. Conversations with the patient and/or decision maker regarding the perioperative course of action are needed. If an AND is modified, it must be documented along with verifying the “time” the modification is in place. Because many geriatricians initiate advanced directives and code status discussions with their patients independent of surgery, their presence and input are critical in this shared decision-making.

Many older patients with implantable cardioverter defibrillators (ICDs) undergo surgical and minimally invasive procedures. Studies show that 30% to 40% of patients with ICDs might experience depressive and posttraumatic stress symptoms related to their need for the device. It is the role of the anesthesiologist to take these symptom burdens into account when these patients present to the perioperative area and to allay any anxiety by letting them know how their heart function will be continuously monitored (eg, continuous ECG, pulse oximetry, and arterial pressure monitoring to provide beat-to-beat display, if indicated). Other nuances specific to the intraoperative management of ICDs include readily available urgent transcutaneous pacing, defibrillation or cardioversion, careful cautery pad placement so that the current from the electrocautery unit does not interfere with the ICD generator or leads, and the surgeon’s use of bipolar as opposed to monopolar cautery. Importantly, all anesthesiologists, irrespective of their subspeciality, are expected to understand equipment characteristics,

troubleshooting, and rescue strategies when patients with ICDs are under their care.

The geriatrician can aid in preoperative assessment of such patients by communicating with the anesthesiologist and/or preoperative physician as to the reason for the pacemaker or an ICD placement as well as whether or not the patient is dependent on the pacemaker function. Patients with severe atrial-ventricular (AV) nodal dysfunction or AV nodal ablation will be pacemaker-dependent. Patients who have biventricular pacemakers, 100% ventricular pacing is a sign of a properly functioning device and is not necessarily indicative of pacemaker dependency. For patients who have ICDs, it is important for the anesthesiologist to know if the device was placed for primary prevention in a patient with risk factors for lethal arrhythmias due to decreased ejection fraction or for secondary prevention in a patient who has a history of lethal arrhythmias. Taken together, it is important for the geriatrician to communicate with the anesthesiologist as to any information they might have regarding the patient’s ICD, and to also help allay any anxiety relating to the planned procedure, device function, and/or dependency.

Based on the current literature, there is unconvincing evidence that one anesthetic technique or cardiac surgical approach is superior to others in the older surgical patient in terms of limiting postoperative dysfunction, for example, delirium and cognitive dysfunction, the most common postoperative complications in the older adult. As older adults are more sensitive to intravenous anesthetics, volatile agents, and opiates due to age-related changes in pharmacokinetics and pharmacodynamics, anesthetic dosing is age-adjusted and anesthetic depth continuously monitored by end-tidal anesthetic concentrations, physical signs and often brain function monitoring with processed EEG. While there is no recommended pharmaceutical for preventing POD after noncardiac and cardiac surgery, best practice consensus guidelines advocate nonpharmaceutical interventions (eg, staff education, early mobilization, adequate multimodal pain control and assessments, frequent orientation, sleep-wake cycle preservation, early postoperative use of hearing and visual aids, etc) and avoidance of high-risk medications such as benzodiazepines. As a member of the interdisciplinary care team, anesthesiologist’s role extends from focusing on comorbidities

and initiating preoperative optimization to intra- and postoperative care strategies aimed at analgesia, while maintaining homeostasis and minimizing the risk of PNDs. Given that surgical procedures are common at the end of life, preoperative and then immediately presurgical conversations with the patient and/or decision maker regarding the perioperative course of action should involve the surgeon, anesthesiologist, and the patient’s primary care physician to ensure that the patient’s wishes and goals of care are understood and documented.

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The US population is aging and increasing numbers of older adults are undergoing surgery. Adults 65 and older account for more than 40% of all inpatient operations and 33% of outpatient operations performed annually in the United States. With advances in care and surgical technique, it is not uncommon to have surgical patients in their 80s and 90s and beyond.

However, operations in older adults are associated with a high risk of prolonged hospitalization, surgical complications, and functional decline. As we place increasing focus on improving these outcomes, we have found that chronological age is not sufficient for predicting surgical risk. Frailty has been shown to be a stronger predictor of perioperative morbidity and mortality than age alone, and we are now working to refine how we assess frailty in surgical patients so that we can have meaningful discussions with patients and their families about the impact and possible outcomes of surgery.

In contrast to younger patients, many older surgical patients value maintenance of functional independence and quality of life (QOL) as much as or even more than quantity of life. In this context, the long-standing traditional measures of surgical quality and a successful surgical outcome— short hospital stay, few postoperative complications, and avoidance of 30- day readmission must be reconsidered. Functional recovery following surgery is now perhaps the most important measure of surgical success in this older patient population and globally encompasses physical well-being as well as cognitive, psychological, emotional, social, and even economic recovery over a period of a year or more.

This chapter will review traditional surgical outcomes as well as patient-centered outcomes of functional and cognitive recovery and QOL for older patients undergoing surgery.

Older patients have more comorbidities, less physiologic reserve, and often a less robust social support network to withstand the physical insult of surgery as well as the stress put on their nutritional, psychological, and emotional well-being. Several studies using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database, which includes patients having a wide range of surgical procedures at academic and community hospitals across the country, showed that older patients, as a group, had significantly higher morbidity (1.2–2 times higher) and 30-day mortality (2.9–6.7 times higher) than younger patients.

Additionally, patients older than 75 years were significantly more likely to have a prolonged hospital stay. Approximately 60% of patients older than 75 years remained in the hospital longer than 7 days after a major gastrointestinal tract operation.

In the past, we used patient’s age to guide expectations on postoperative recovery and even to decide whether we would offer surgery to a patient.

However, if selected appropriately, older patients undergoing even very high-risk procedures can have good outcomes and benefit from surgery. Frailty, or physiological decline and increased vulnerability to stressors, is a key factor in determining an older patient’s ability to withstand and recover from surgery. Frailty does not correlate with chronological age and may not correlate with the American Society of Anesthesiologists physical status classification score. There are many methods to try to determine frailty in

surgical patients but regardless of how frailty is measured, frail patients have been shown in multiple studies to have increased in-hospital, 30-day, 90-day, and 1-year mortality, increased rates of postoperative complications, longer lengths of stay, and increased need for institutionalization at discharge compared to nonfrail geriatric surgery patients.

A 2014 study of 180 patients who underwent surgical treatment for gastric cancer reported that postoperative mortality was 23% among patients who were frail, compared with 5% among patients who were fit. A 2016 systematic review including 23 studies of patients with mean age of 75–87 years undergoing a wide variety of oncologic or nononcologic surgery and using 21 different instruments to measure frailty found that frail patients had increased 30-day mortality (odds ratio [OR] 1.4–8.33), 1-year morality (OR 1.1–4.97), 2-year mortality (OR 4.01), and 5-year mortality (OR 3.6)

compared with nonfrail patients. Finally, in a large study of over 14,000 inpatient and outpatient operations, increasing frailty correlated with increased rates of major morbidity, readmission, mortality, and discharge to facility for inpatient procedures as well as increased unplanned admission for outpatient procedures. Not surprisingly, direct costs per patient also increased with increasing frailty in the inpatient cohort (Modified Hopkins Frailty Score: low, $7045; intermediate, $7995; high, $8599).

In addition to postsurgical complications, hospitalized older adults undergoing surgery are at risk for geriatric events (delirium, dehydration, falls or fractures, failure to thrive, and pressure ulcers), which can contribute to worse outcomes. A large study using the National Inpatient Sample including over 800,000 patients undergoing one of the five most common elective procedures in adults 65 years or older (total knee arthroplasty, right hemicolectomy, carotid endarterectomy, aortic valve replacement, and radical prostatectomy) analyzed the rates of perioperative geriatric events.

Among admissions for adults 65 years or older, 2.4% experienced a geriatric event. Rates of geriatric events increased with age and varied by procedure, ranging from 1.0% in admissions for radical prostatectomy to 10.3% in admissions for aortic valve replacement. The most common geriatric event in adults 65 years or older was dehydration (1.1%). Among patients 75 years or older, the most common geriatric event was delirium (1.7%).

Looking more specifically at high-risk geriatric surgery (operations associated with a > 1% inpatient mortality in patients = 65 years old), a study including over 500,000 geriatric patients found that the overall inpatient mortality rate was 4.6%. The median postoperative length of stay was 5.4 days and rate of discharge to nursing facility was 28.8%. In this study, mortality, postoperative length of stay, and rate of discharge to nursing facility were influenced by the volume of high-risk geriatric operations performed at the hospital and the proportion of high-risk operations at that center which were performed on geriatric patients. Higher proportion was associated with decreased mortality and shorter length of stay suggesting that these centers may be better equipped to manage the unique health care needs of these older adults undergoing high-risk surgery and provide high-quality geriatric-focused care.

Surgical outcomes in older patients are improved when these patients are treated in a geriatric-focused health system and several organizations are prioritizing the improvement of geriatric patient care. Some physicians may be fortunate to work in an Age-Friendly Health System, which strives to provide evidence-based high-quality care based on the geriatric 4Ms—What Matters Most, Medication, Mentation, and Mobility—to all adults in their system (Multicomplexity being implicit in this patient population and not a separate M). The Age-Friendly Health System movement began in 2017 and now comprises several hundred hospitals, practices, and postacute long-term care communities who are focused on caring for older adults. Another entity striving to improve the care of older surgical patients is the American College of Surgeons Geriatric Surgery Verification Program, which includes 32 surgical standards designed to systematically improve surgical care and outcomes for this patient population. These standards overlap with the framework of the Age-Friendly Health System and bridge preoperative, postoperative, and transitions of care periods for the patient, but also include recommendations on improving facilities, equipment, data surveillance, and community outreach to build an infrastructure that is focused on the surgical care of older adults.

Geriatric co-management of patients has been associated with improved outcomes including shorter length of stay and lower rates of complications and mortality for older patients. Currently, the most common co-management model is the orthogeriatric care model for the management of hip fractures in older patients. Each hospital has developed their own unique co-management model and these fall into three categories: Routine Geriatric Consultation (routine geriatrician consultation on older patients in an orthopedic ward); Geriatric Ward (care within a geriatric ward with the orthopedic surgeon acting as consultant); and Shared Care (integrated care model with both orthopedic surgeon and geriatrician sharing responsibility for the care of the patient). Routine Geriatric Consultation is the most common orthogeriatric model. Most studies of this model show that orthopedic geriatric collaboration improves outcomes versus standard of care for older patients although the types of outcomes differ in various studies.

In another retrospective study of over 1800 patients (= 75 years old) who underwent elective cancer-related surgery, patients who received geriatric co-managed care were compared with those who did not. Although adverse surgical events were not significantly different, the probability of death

within 90 days was 4.3% for the geriatric co-management group versus 8.9% for the surgical service group. Patients in the geriatric co-management group also received more inpatient physical and occupational therapy, speech and swallow rehabilitation, and nutrition services than patients managed by the surgical service alone and this geriatric-focused multidisciplinary care may have contributed to their improved outcomes. Most hospitals now use standardized enhanced recovery after surgery (ERAS) pathways tailored to specific operations that span the preoperative, intraoperative, and postoperative periods. These ERAS pathways have been very successful in decreasing complications and length of stay, but the same pathway is used for young and old surgical patients and patients who are frail or fit. One current area of innovation is in tailoring the ERAS pathway to address the unique needs of older surgical patients and in many cases, this includes automated consults to inpatient support services such as physical therapy and nutrition services based on certain screening criteria.

In a 2002 seminal paper exploring the treatment preferences of older adult patients with serious illnesses, patients were more likely to be willing to undergo a treatment if the possible outcome was death than undergo the same treatment if the possible outcome was severe cognitive or functional impairment. This study and many subsequent studies pushed us to realize that our traditional surgical outcomes measures were not appropriate for the unique older surgical patient population. Older patients wanted to know about their expected cognitive and functional recovery after surgery and their ability to remain independent before making a decision about whether to proceed with the surgery. Until recently we did not measure these outcomes, which were difficult to quantify and required a much longer follow-up period of up to a year or longer, compared with traditional outcomes. Several prospective longitudinal cohort studies of older adults have contributed to our understanding of functional recovery after surgery. In most studies, majority of patients had an initial functional decline, but were able to recover to close to their presurgery level of function over a period of 6 months to a year.

The Precipitating Events Project is a longitudinal study of 754 community-dwelling persons 70 years or older who were initially nondisabled in four basic activities of daily living: bathing, dressing, walking, and transferring. These participants were queried using monthly interviews to evaluate functional status (whether they need assistance for four essential activities [bathing, dressing, walking, and transferring], five instrumental activities [shopping, housework, meal preparation, taking medications, and managing finances], three mobility activities [walk ¼ mile, climb flight of 7 stairs, and lift/carry 10 pounds], and whether they had driven a car in the past month) in addition to comprehensive assessments every 18 months. From 350 admission for major surgery, 69 admissions had no change or improved disability at the first follow-up. The remaining 216 participants undergoing 266 major surgeries had initial increased postoperative disability but by their 6 month follow-up, 174 (65.4%) had recovered to their presurgery level of function, 76 (28.6%) had not reached their presurgery level of function but were alive, and 16 (6%) had died. Two factors significantly associated with an increased likelihood of functional recovery were having an elective operation (hazards ration [HR] 1.72) and being nonfrail (HR 1.60). Additionally, in this cohort, intervening illnesses and injuries leading to hospitalization, emergency department (ED) visit, or restricted activity were common in the year after major surgery and were more closely associated with functional decline than were traditional risk factors such as chronic conditions, obesity, depressive symptoms, or hearing impairment. Ultimately, a quarter of patients did not recover to their premorbid level of function in the year following surgery and the vast majority of patients experienced at least one episode of functional decline during the study period.

In addition to the impact of major surgery, subsequent hospitalizations are also associated with functional decline. The Successful Aging after Elective Surgery (SAGES) study, an ongoing prospective cohort study of 566 adults aged 70 and older undergoing major scheduled noncardiac surgery, showed that readmissions, whether associated with the index surgery or not, were associated with delays in functional recovery. Over an 18-month period, 253 participants (45%) had 503 readmissions (143 patients had one, and 112 had

two or more, with a maximum of 12); 203 (36%) participants reported 345 readmissions that were unrelated to the index hospitalization. The degree of functional impairment increased progressively with the number of

readmissions, potentially due to the harmful effects of delirium, immobilization, sleep deprivation, malnutrition, and psychological stress experienced during each hospital admission.

Another measurement of functional decline, loss of independence (LOI), is now gaining attention. The definition of LOI varies across studies, but it encompasses a decline in functional status or increased care needs. In a study of patients undergoing inpatient surgery at a hospital participating in the ACS NSQIP Geriatric Surgery Pilot Project, LOI was measured at discharge and was characterized by one of three changes: a decline in function according to activities of daily living (ADLs), a decline in mobility requiring a new mobility aid, or an increase in care needs, such as a need for new home-care services or discharge to a nonhome destination. At the time of discharge, 26% of patients experienced a decline in functional status and 30% had a decline in mobility. Forty-six percent of patients had increased care needs (27.8% required additional supportive services at home, 18.2% required discharge to a nonhome destination). Overall, 60% of patients experienced at least some degree of LOI. LOI increased significantly with age: 50% of patients between 65 and 74 years, 67% of patients between 75 and 84 years, and 84% of patients 85 years and older.

Delirium is the most common surgical complication in older adults, affecting up to half of patients postoperatively, and it is closely linked to poor patient outcomes. Postoperative delirium is associated with a two- to fivefold increased risk of major postoperative complications, a threefold increased risk of institutional placement at discharge, longer hospital stays, and increased rates of readmission and mortality. In addition, Medicare cumulative costs attributable to delirium in older surgical patients were found to be $44,291 per patient over 1 year following surgery and $56,474 per patient with severe delirium over the year following surgery. Despite these significant adverse results, postoperative delirium is significantly underrecognized and therefore undertreated. It is equally important to note that delirium is preventable in up to 40% of patients with relatively simple adjustments in perioperative care. The prevention and management of delirium in surgical patients need as much targeted emphasis in surgical education as other more traditional complications.

An episode of postoperative delirium has as significant an impact on patient outcomes as a major postoperative complication. In a large cohort of patients 70 years or older undergoing major orthopedic, vascular, or abdominal surgery, 8.3% developed a major postoperative complication and 24% developed delirium. Patients who had a major complication such as unstable arrhythmia, respiratory failure, or stroke, but did not have delirium had increased length of stay (relative risk [RR], 2.8; 95% confidence interval [CI] 1.9–4.0). However, patients with delirium but no major complication had prolonged length of stay (RR 1.9; 95% CI 1.4–2.7) as well as increased institutional discharge (RR 1.5; 95% CI 1.3–1.7) and increased 30-day readmission (RR 2.3; 95% CI 1.4–3.7). Patients who had both a major complication and delirium had the highest rates of adverse outcomes with a mean length of stay of 13 (SD 11) days and increased institutional discharge (RR 1.8; 95% CI 1.4–2.5) and 30-day readmission (RR 3.0; 95% CI 1.3–

A number of studies have looked at the relationship between postoperative delirium and postoperative cognitive dysfunction. Postoperative delirium and postoperative cognitive dysfunction share risk factors and may co-occur, but their relationship over the postoperative period is unclear. A study looking at the association between postoperative delirium and the risk of postoperative cognitive dysfunction at 1 month, 2 months, and 6 months after major noncardiac surgery showed that postoperative delirium increased the risk of postoperative cognitive dysfunction at 1 month postoperatively, but there was no association between postoperative delirium and cognitive dysfunction at 2 and 6 months after major noncardiac surgery.

The Postoperative Cognitive Dysfunction in Elderly Cancer patients (PICNIC) study was a prospective observational study of patients aged 65 or older who underwent oncologic surgery. Three cognitive domains (memory, executive function, and information processing speed) were evaluated at baseline (approximately 2 weeks before surgery) and 3 months postoperatively. Of the 219 patients included in the analysis, 26 (12%) had cognitive decline 3 months postoperatively, whereas 117 (53%) patients had improved cognitive scores. Advanced age (> 75 years old), lower preoperative Mini-Mental State Examination (MMSE) score, and major surgery (surgery with anesthesia lasting > 210 minutes) were risk factors for cognitive decline at 3 months postoperatively. In patients with advanced age

(> 75 years) or those undergoing major surgery, 18% showed cognitive decline and in patients who additionally had a lower preoperative MMSE score, the incidence was 37%. During the study, 10% of patients were diagnosed and treated for postoperative delirium.

Quality of life (QOL) is tightly intertwined with functional and cognitive recovery, but studies show that postoperative QOL can exceed the preoperative level even for patients who have postoperative functional decline or suffer a complication. A study of patients age 75 and older undergoing surgery for colorectal or gastric cancer measured activities of daily living (ADLs) and QOL at baseline and then at 1 month, 3 months, and 6 months postoperatively. Twenty-four percent of patients showed a decrease in ADL at 1 month postoperatively, but most patients recovered with only 3% showing a decline at the sixth postoperative month. QOL of the patients similarly fell immediately after surgery but then rapidly recovered to equal or better than their preoperative level, 3 to 6 months after surgery. In another study of patients 70 years or older undergoing elective resection for colon or rectal cancer evaluated with the EORTC-QLQ-C30, emotional function and QOL improved for both frail and non-frail patients at 3 months. At long-term follow-up (median time 22 months after the operation), emotional function and QOL scores had decreased from the postoperative peak but still remained above baseline.

Another measure of QOL or independence is the amount of time spent at home following oncologic surgery. In a study of over 80,000 people undergoing oncologic surgery, older adults spent more than 98% of their time at home over the 5 years following surgery. The amount of time at home varied with the type of oncologic surgery. Breast surgery had the highest likelihood of spending time at home and gastrointestinal surgery had the lowest likelihood of spending time at home over the 5 years following surgery. The amount of institutionalized time increased over time. Most patients who survived the surgery were likely to have 14 or less institution days per year for the first four postoperative years. However, in the fifth year, 50% of patients who were still alive were likely to experience more than 14 institution days per year. Advancing age, preoperative frailty, lower socioeconomic standing, rural residency, high-intensity surgical procedure,

and gastrointestinal, gynecologic, or oropharyngeal cancers were associated with less time at home.

Minimally invasive surgery is now expected by most patients but the benefits in older patients are not always as clear. QOL was compared between patients undergoing laparoscopic versus open pancreatic resection to determine if minimally invasive surgery improved QOL. In both the minimally invasive and open surgery groups, physical, functional, and QOL scores decreased in the immediate postoperative period but returned to baseline by 6 months postoperatively. Patients who experienced a severe complication had greater declines in QOL than patients who did not have a complication regardless of the surgical approach, emphasizing that a safe operation is the best approach to optimize patient QOL.

In order to give older patients the best understanding of their anticipated surgical outcomes, we can no longer rely simply on estimates of traditional outcome measures such as morbidity and mortality but must find a way to incorporate geriatric patient-centered outcomes as well. This is a complex and multidimensional risk calculation that is unique to each patient and yet must be determined in a timely manner so that surgical decisions can be made. The ACS NSQIP Surgical Risk Calculator is a decision support tool that provides estimates of risk for 12 30-day outcomes using 21 preoperative risk predictors. Using data collected from 21 ACS NSQIP Geriatric Surgery Pilot Project hospitals, six new geriatric risk factors (living situation, fall history, mobility aid use, cognitive impairment, surrogate-signed consent, and palliative care on admission) were added in order to predict four postoperative geriatric outcomes (pressure ulcer, delirium, new mobility aid use, and functional decline). Using a geriatric-enhanced surgical risk calculator like this is critical to enabling clinicians to better guide patients and their families as they make decisions about their health care and ultimately to improving surgical outcomes for these patients.

Additionally, older patients can benefit from a personalized care plan that incorporates their complex needs and personal goals. At our institution, we are striving to develop and improve this model, which will span the preoperative, intraoperative, and postoperative segments of a patient’s experience and will provide the foundation for improving surgical quality and outcomes for our older patients (Figure 29-1).

Older adults as a group become more diverse in their health care conditions and their personal goals as they age. The definition of surgical quality and a good outcome is unique to each patient. As surgeons, perhaps the most important thing we can do is to ask patients: What matters most to you? For some patients, this may be resecting their tumor, regardless of the risks. For others, it may be living independently for as long as possible. And for others, the best outcome may be focused on symptom relief and palliative care. As surgeons, we are in a unique position to have informed discussions about surgery in the framework of what matters most to the patient and their loved ones and to put patients on the trajectory toward their goals, even if surgery is not desired. In this way, we will be able to help older patients achieve the best outcomes possible.

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Throughout life, nutrition is an important determinant of health, physical and cognitive function, vitality, overall quality of life, and longevity. The quantity and variety of available foods, as well as the meaningfulness of the social interactions provided by meals, are important to psychological well-being.

The composition of the diet and the amount that is consumed are strongly linked to physiologic function. When a well-balanced diet adequate to meet the body’s metabolic demands is not maintained, malnutrition may develop with consequent detrimental effects on health and well-being.

Malnutrition can have many manifestations. As outlined below, a diet that is deficient in one or more required nutrients (eg, calories, protein, minerals, fiber, or vitamins) can lead to a state of nutritional deficiency. The greater the magnitude and duration of the nutritional deprivation and the more fragile the individual, the more likely nutritional deficits will produce noticeable body compositional changes, functional impairments, or overt disease. Even borderline dietary deficiencies can have important health consequences such as producing subtle organ system impairments, diminished vitality, or increasing the individual’s susceptibility to disease. Protein and protein- energy undernutrition are two of the most common, frequently unrecognized, and potentially serious forms of nutritional deficiency. The prevalence of

these conditions is particularly high among chronically ill older individuals and those in hospitals, nursing homes, and other institutional settings.

Although there is a complex interrelationship between nutrition, disease, and clinical outcomes, protein and protein-energy undernutrition appear to be significant contributors to disease-related morbidity and mortality in these populations.

risk of developing disabling chronic diseases such as severe osteoarthritis, type 2 diabetes, and heart disease.

At the other end of the spectrum, the persistent consumption of excess quantities of one or more nutrients can have similar untoward consequences. Forms of malnutrition that result from excess consumption include

hypercholesterolemia, hypervitaminosis, and obesity. Obesity is the most common nutritional disorder of advanced age in western societies, with a high prevalence among noninstitutionalized free-living older adults. Many obese older individuals have other nutritional disorders. Among chronically ill or functionally debilitated obese older individuals, protein undernutrition is a common, serious, and frequently unrecognized problem that can develop for many reasons including an imbalanced diet, disease, and inactivity.

Recognizing and maintaining an optimally balanced diet is an important challenge, particularly when individuals age. The challenge is particularly great for older people who already are malnourished, especially if they have nutritional disorders that developed earlier in life, such as obesity, osteoporosis, or protein undernutrition. Even healthy individuals often fail to maintain an optimal diet due to lack of knowledge, resources, or willpower. Age-related acute and chronic diseases, physical disabilities, social isolation, use of multiple medications, depression, impaired cognitive ability, and dysregulation of appetite control may contribute further to poor eating habits and the development or exacerbation of nutritional disorders. In turn, inappropriate dietary intake and poor nutritional status can impact the progression of many acute and chronic diseases such as coronary heart disease (CHD), cancer, stroke, diabetes, and osteoporosis, which are among the 10 leading causes of death in the United States. Approximately two-thirds of all deaths within the United States are due to diseases associated with poor diets and dietary habits.

Assessing diet quality of the older people is critical to addressing issues relevant to their health and nutritional status. Such an assessment must be based on knowledge of what constitutes a balanced diet for a given individual. The goal of this chapter is to identify an approach to nutrition evaluation and management that takes into account the unique needs, limitations, and desires of each older individual. The chapter examines the interrelationship between nutrition, activity, disease burden, and health outcomes and then focuses on age-related changes in body composition and appetite regulation that affect nutritional status and nutrient requirements. The chapter includes discussion of both undernutrition and obesity as well as specific dietary considerations for optimal health.

Although nutrition is a vital component of good health, it cannot be evaluated in isolation. The relationship between nutrient intake and health is influenced by other factors, most notably activity level, disease burden, and advancing age. A basic understanding of these interrelationships is essential in order to assess the potential benefits and limitations of nutritional interventions.

Nutrition and physical activity are closely linked, each having vitally important and interacting effects on body composition, functional ability, and well-being. The balance between nutrient intake and physical activity is particularly important in determining muscle mass and strength, body fat content and distribution, and bone density and resilience. A detailed description of the importance of physical activity in these relationships is provided in Chapter 54.

To preserve existing muscle mass and strength, it is necessary to maintain both an adequate level of physical activity and a balanced diet that includes sufficient protein, energy, vitamins, and minerals to meet metabolic demands and prevent negative nitrogen balance (as discussed in detail further). It is not known precisely what level of physical activity is needed to prevent loss of existing muscle mass and strength in older adults. However, even a week or two of bed rest or similar degrees of activity restriction can result in noticeable loss of muscle mass, strength, and function even when the diet is adequate, and the individual is otherwise healthy. When an inadequate diet and inflammation are combined with inactivity, as occurs with serious illness, muscle loss can be even more rapid and profound. Overfeeding does not prevent muscle atrophy associated with inactivity and may exacerbate the functional consequences since the excess nutrients are converted to fat.

Consumption of a protein meal stimulates muscle protein synthesis. However, nutrition alone has never been demonstrated to be an effective method of repleting muscle mass, improving strength, or increasing endurance in frail older individuals who have experienced a recent loss of weight. Efforts at repletion should focus on both increasing nutrient intake and exercise. Based on studies of healthy older men, the combination of progressive resistance muscle strength training and a high protein diet (containing up to 1.6 g of protein/kg body weight/day) may be the most effective method of improving muscle mass. The role of special formula amino acid supplements has yet to be determined.

Exercise and nutrition also play a critical role in maintenance of optimal bone density and strength. As discussed in Chapter 51, the nutrient needs of bone include the correct balance of protein and energy and adequate intake of vitamins and minerals, especially vitamin D and calcium. The importance of exercise for optimal bone health is also described in Chapter 54. Osteopenia can develop despite an optimal diet if exercise or other weight-bearing activities are not adequate. Because of its apparent beneficial effects on bone mineral density (BMD), exercise should be combined with an appropriate diet for both prevention and treatment of osteoporosis and fracture-related disability.

Having both direct and indirect effects on numerous metabolic processes within muscle, bone, and adipose tissues, exercise has a major impact on how nutrients are utilized by the body during health and illness. By inducing an increase in the mass and metabolic capacity of muscle, exercise effects energy expenditure, glucose metabolism, and size of protein reserves in a manner that counteracts some of the effects of aging and thus has important nutritional implications for individuals as they grow older. Total energy expenditure (TEE) represents the sum of basal energy expenditure, post- prandial thermogenesis, and the energy expenditure of activity. Muscle represents not only the primary source of energy expenditure during physical activity, it is also the primary contributor to basal energy expenditure, which may represent 50% to 80% of TEE. With advancing age, there is a parallel decline in muscle mass and both basal and total daily energy expenditure that may be partially or fully accounted for by the fact that people tend to become more sedentary as they grow older.

Exercise-induced increases in muscle size or protein content result in greater body protein reserves that can be critical to survival during episodes of nutritional deprivation that usually accompany profound physiologic stress such as trauma, sepsis, or other acute disease. Such physiologic insults trigger an acute inflammatory response that causes ketogenesis to be suppressed, leaving glucose as the primary energy source available to the body. The problem is invariably compounded by reduced nutrient intake that results as a consequence of the anorexia and gastrointestinal tract dysfunction induced by the inflammatory response. With nutrient intake suppressed, gluconeogenesis becomes the predominant source of glucose. Since the substrate for gluconeogenesis is provided by catabolism of skeletal muscle, LBM becomes an important determinant of survival. Once LBM falls below

a critical level, the chance of surviving a serious acute illness diminishes dramatically. Studies conducted within the Warsaw Ghetto, hospital intensive care units, and other settings suggest that a loss of more than 40% of baseline lean mass is incompatible with life. Indeed, very few healthy people have a LBM that is less than 70% of the mean for that of adults between 20 and 30 years.

In addition to inducing muscle hypertrophy, exercise also affects insulin sensitivity and glucose disposal directly and plays a synergistic role with diet in maintaining a healthy weight and a sense of well-being. These effects of exercise can be important adjuncts to good nutrition in the prevention and treatment of hypertension, diabetes, and osteoporosis.

There is a complex interrelationship between nutrition, health status, and clinical outcomes. Although a full discussion of this topic is beyond the scope of this chapter, it is important to emphasize several key points. First, nutrient requirements and the ability to metabolize select nutrients are influenced by many disease states. In addition, many diseases compromise the older individual’s ability to consume adequate amounts of all nutrients. This can occur through a number of mechanisms including disease-induced suppression of appetite, alteration of the normal swallowing mechanism, maldigestion or absorption, or loss of self-feeding ability.

The detrimental effects of disease on nutrient metabolism often become more pronounced with advancing age. This is particularly true of the many acute and chronic diseases that induce an inflammatory response, including acute and chronic infections, congestive heart failure, chronic pulmonary disease, cancer, end-stage renal disease, and rheumatoid arthritis. As described in detail in Chapter 3, with advancing age, the inflammatory response often becomes dysregulated as indicated by persistently elevated serum concentrations of proinflammatory cytokines and other inflammatory mediators including interleukin (IL)-6, IL-1(beta), tumor necrosis factor (TNF)-alpha, and possibly IL-8 and others. IL-1, IL-6, and TNF-alpha all contribute to the loss of skeletal muscle, fat tissue, and bone mass that characterizes inflammation-associated cachexia. Although anorexia is almost always a contributing factor, the inflammation-induced loss of fat and lean mass is often refractory to nutrition support. Through a number of different mechanisms, proinflammatory cytokines create a state of muscle

hypercatabolism by suppressing muscle protein synthesis and/or accelerating muscle protein breakdown independent of dietary factors.

Since these potentially deleterious effects of disease can be difficult to predict, older individuals with one or more acute or chronic health problems should have frequent reassessments of their nutritional status and their nutritional care plan revised as necessary. Although nutrient intake may not be adequate to completely reverse inflammation-induced catabolism, a low nutrient intake will accelerate the development of cachexia. Optimally, good nutritional care should be part of the overall plan of medical intervention aimed at treating the underlying pathology as well as addressing protein and energy deficits. Although a number of specific nutrients are being studied to determine their value in counteracting inflammation-induced loss of LBM, there is not yet adequate evidence that any given dietary supplement is more effective than current standard dietary or nutrition support practices.

With advancing age, there are significant changes in body composition that affect the nutritional needs of the individual. Weight increases steadily on average from age 30 to 60 years primarily due to an increase in total body fat. After age 60, weight usually stabilizes, and then begins to decline. The incidence as well as the potential causes of weight loss increase with age, particularly beyond age 75.

Regardless of whether or not weight changes, advancing age is characterized by a progressive loss in LBM, a relative increase in fat mass, and a redistribution of fat from peripheral to central locations within the body. These changes generally begin in the third decade and increase at an accelerated rate after age 65. This late acceleration may be due to loss of LBM plus the increased prevalence of chronic diseases in old age. The loss of LBM consists predominantly of skeletal muscle, particularly type II or fast twitch fibers. Central LBM, such as the liver and other splanchnic organs, is relatively preserved. As reviewed in detail in Chapter 49, muscle mass may decline by up to 45% between the third and eighth decade of life (see Figures 30-1 and 30-2). The quality of muscle may also change. With advancing age, there is a gradual infiltration or replacement of muscle by fat, as has been documented by computed tomography. Even accounting for body

size, height, and other aspects of body composition, fatty infiltration into muscle is associated with symptomatic functional decline, poorer physical function, and change in strength.

FIGURE 30-1. Declining muscle mass with increasing age. (Data from Janssen I, Heymsfield SB, Wang ZM, et al. Skeletal muscle mass and distribution in 468 men and women aged 18-88 yr. J Appl Physiol (1985). 2000;89[1]:81–88.)

FIGURE 30-2. Cross-sectional computed tomography images of the midthighs of a younger and an older woman demonstrating the decline in muscle mass and relative increase in fat mass with age.

The loss of muscle mass with age appears to be the result of multiple interrelated factors including age-related changes in metabolism, function, or structure of organ tissues, disease, medical therapeutics, heritability, and behavior and lifestyle choices of the individual (Chapter 49). The declines in nutrient consumption and activity level that often accompany older age are possibly modifiable contributors to the loss of muscle mass. An accelerated loss of muscle mass can occur when a serious illness requires treatment with steroids or other antianabolic drugs or is accompanied by low nutrient intake and the need for prolonged bed rest. The loss of muscle mass with age is

closely linked with a reduction in muscle strength and exercise capacity, which contribute to functional impairments and disability as well as to the development of CHD, diabetes mellitus, and other diseases that can contribute to further decline in a vicious cycle leading to frailty (see Chapter 42).

In parallel with the loss of LBM, there is an increase in the relative amount and the distribution of body fat with advancing age. Between the second and ninth decades of life, the percentage of body weight that is fat increases by 35% to 50% in women and to an even greater extent in men. Whether or not total body weight changes, intra-abdominal (visceral) fat increases quantitatively and proportionally more than peripheral fat mass. In females, the accumulation of intra-abdominal fat accelerates at menopause and represents primarily a shift from peripheral sites. In males, the increase in intra-abdominal fat with age represents primarily an increase in total body fat mass. For a given waist circumference, older adults have greater visceral fat than young adults, and men have greater visceral and less subcutaneous fat than women.

Maintenance of a stable weight requires a steady balance between nutrient intake and energy expenditure. With advancing age, the metabolic, neural, and humoral pathways that normally maintain this delicate balance by regulating appetite and hunger begin to lose their compensatory responsiveness to changes in energy demands. Psychological, socioeconomic, and cultural influences and numerous disease processes further contribute to the dysregulation (Table 30-1). From the third to seventh decade of life, these factors integrate to create an imbalance usually favoring a tendency toward weight gain and increased fat deposition, at least in societies where food is plentiful and the physical demands of life are light.

However, after age 70, the risk of losing weight increases steadily with each year of survival. Loss of body weight correlates with low dietary energy intake, which is common among both healthy and frail older adults. The late- life weight decline is associated with many chronic conditions that increase risk of death in old age, including Alzheimer disease.

TABLE 30-1 ¦ FACTORS CONTRIBUTING TO INADEQUATE NUTRITION IN OLDER ADULTS

Pathophysiologic Changes that Lead to Loss of Taste, Smell, and Appetite with Advancing Age

Numerous pathologic and age-related physiologic changes can have a deleterious effect on eating habits and the likelihood of maintaining an adequate diet (see Table 30-1). This can include deterioration in sight, olfactory function, taste sensation, or ability to feel the temperature and

texture of food in the mouth, all of which can contribute to a diminished appetite. Even healthy older individuals experience such changes. Much greater losses in taste and smell occur in association with medication usage and other health-related concerns. Table 30-2 contains a representative listing of medications that can cause appetite suppression and losses of olfactory function and taste sensation. Poor oral health (Chapter 32) and many diseases that decrease mastication, salivary flow, or ability to swallow (Chapter 31) can also lead to deterioration in taste and smell to adversely affect appetite.

TABLE 30-2 ¦ CLASSES OF MEDICATIONS THAT CAN SUPPRESS APPETITE AND ALTER OLFACTORY FUNCTIONA

In addition to the special senses, there are various neural and humoral pathways within the gut that may change with advanced age and possibly contribute to the inability of many older individuals to adequately regulate food intake. There are also large numbers of hormones and other gut-derived substances that are thought to influence appetite and food metabolism, as shown in Table 30-3. It is theorized that age-related changes in some or all of these substances may adversely affect food intake in older adults.

TABLE 30-3 ¦ HORMONES AND CHEMICALS THAT MAY PLAY A ROLE IN APPETITE AND OBESITY

After the seventh decade of life, psychological, socioeconomic, and cultural factors are increasingly important for an adequate diet (see Table 30-1).

Depression is a highly prevalent, frequently unrecognized, and potentially treatable cause of a poor appetite and weight loss. Similarly, bereavement is associated with a lack of appetite. Eating alone may be associated with a lower energy intake, and the presence of family and close friends leads to greater nutrient intake. Within institutional settings, particularly nursing homes, physical environment and ambience within the dining areas are known to affect appetite and can often be improved. Elimination of therapeutic diets (eg, low salt or low cholesterol) may also be of benefit.

Such restricted diets often make meals much less appetizing for the older residents and may add little to disease management. For these reasons, the American Dietetic Association in collaboration with the Centers for Medicare and Medicaid Services, Pioneer Network, and others published a position statement suggesting that use of therapeutic diets in nursing homes be restricted.

Obesity is defined as an unhealthy accumulation of body fat, which leads to a higher risk of medical illness and premature death. Although not ideal, body mass index (BMI) and waist circumference are the most widely utilized metrics for classifying overweight and obesity. Both are easily obtained and highly validated measures. BMI is calculated as body weight in kilograms

divided by height in meters squared (kg/m2), while waist circumference is a direct measure obtained halfway between the iliac crest and the lower anterior ribs, with the individual standing, and at the end of expiration.

The definition of body weight categories does not currently vary by age or race. Normal weight is considered to be a BMI between 19 and 25; overweight, a BMI of 25 to less than 30; and obesity, a BMI of 30 or more. Waist circumference is used as an index of central/abdominal adiposity and

is clinically useful in further categorizing an individual based on cardiometabolic risk. Traditionally, abdominal obesity is defined as a waist circumference 89 cm (35 inches) or more for women and 102 cm (40 inches) or more for men. A waist-to-hip ratio greater than 1.0 in men and 0.8 in women is another indicator of central obesity. As with BMI, there is controversy as to whether different reference ranges should be used depending on age and ethnicity. While overweight consistently increases morbidity risk in old age, the data on mortality are less consistent, suggesting that guidelines for both BMI and waist circumference should be liberalized for older individuals.

Based on National Health and Nutrition Examination Survey (NHANES) data and current definitions, obesity is highly prevalent among older adults, especially the young old (ie, individuals between the ages of 65 and 80 years). The variability in rates of obesity by race, gender, and age is shown in Figure 30-3. In all race-by-gender groups, the prevalence declines steadily with each decade of life after age 70. In part, this may be a cohort effect. Reflecting trends for the nation as a whole, prevalence rates of obesity in older adults increased significantly between 1999 and 2010, especially among men (see Figure 30-4). It was only among the oldest-old, those older than 80 years, that the prevalence remained stable during this time.

FIGURE 30-3. Prevalence of obesity among adults age 65 and over by sex and race/ethnicity: United States, 2007–2010. (Reproduced with permission from the National Center for Health

Statistics Data Brief No. 106, September 2012, Centers for Disease Control and Prevention,

FIGURE 30-4. Trends in the prevalence of obesity among adults age 65 and over by sex: United States, 1999–2010. (Reproduced with permission from the National Center for Health Statistics Data Brief No. 106, September 2012, Centers for Disease Control and Prevention,

There is controversy regarding the potential benefits and adverse consequences of being overweight or obese after age 65. Potential benefits include protection against bone fractures and a possible survival advantage, at least for select populations of older adults. The lower fracture risk is related to increased fat mass: obese older adults place more stress on their bones and convert more androstenedione to estrone than do slimmer individuals of similar age. Both of these factors contribute to increased BMD. Fat also can also serve as a cushion to protect against the impact of a fall, creating further protection against bone fractures.

Assessing the impact of weight on survival in old age is more complex. Overweight and obese older adults may have a survival advantage during periods of protracted illness, an effect thought to be the result of their greater energy and protein reserves. In general, obesity is associated with greater lean mass; during periods of catabolic stress, the fat and lean mass serve as a functional nutritional reserve.

The impact of obesity on survival in the general population of community-residing older adults usually shows a “J-shaped” relationship

(Figure 30-5). There is a consistent higher mortality with a BMI less than 19. However, this does not necessarily indicate that older adults who have been slender all of their lives are at increased risk of mortality. Rather, the higher mortality probably reflects recently lost weight due to disease in many older adults with a low BMI. However, low protein reserves, whether the result of weight loss or a thinner body habitus, may be the critical factor that is contributing to risk of death in older adults with a low BMI.

FIGURE 30-5. Data from the National Institutes of Health-AARP cohort age 50 to 71 years and followed for a maximum of 10 years. Men (left) and women (right) shown by smoking status in relation to their current BMI. Risks for never smokers are thought to most accurately estimate risk because they remove the effect of smoking on body weight and risk of death. Data adjusted for age, race or ethnic group, level of education, alcohol consumption, and physical activity.

Due to the heterogeneity of various study results, it is unclear what range of BMI is optimal for survival and at what level of obesity all-cause mortality risk begins to increase. However, when different methodologic approaches are used, which in some cases include controlling for cohort mortality and age-related survey selection bias, all-cause mortality appears to increase in direct relationship with BMI in the range of 25 to more than

40. Further complicating the issue, mortality risk in old age may relate to fat distribution as well as total body mass. For any given body weight, mortality risk increases with increasing waist circumference, or more specifically, increasing intra-abdominal or visceral fat mass as measured by modern imaging modalities. Although waist circumference is strongly correlated with

intra-abdominal fat mass, the two metrics are not the same, and direct measures of intra-abdominal fat are more powerful indictors of cardiovascular (CV) risk. However, the mortality risk associated with obesity after controlling for intra-abdominal fat mass is also controversial. Given the many uncertainties about the impact of obesity on overall survival, it is important to consider what other effects excess weight has on the health of older adults.

The impact of obesity on overall health, functional status, and quality of life in older adults is more certain. Overweight in old age is associated with the same risks for disease as in younger populations, and it also exacerbates many age-associated diseases (Table 30-4). In addition to the detrimental metabolic effects of excess body fat, there are adverse mechanical consequences. For example, a relative excess in total body weight to muscle mass leads to osteoarthritis and other disabling conditions while increasing the work required to perform many activities of daily living. The result is a lower functional reserve, chronic pain, and an increased risk of disability.

the basis of size, a situation described as sarcopenic obesity (see Chapter 49); for these individuals, the risk of disability is especially high.

TABLE 30-4 ¦ DISORDERS DIRECTLY CAUSED OR EXACERBATED BY OBESITY

Because of its contribution to many age-related diseases that lead to deterioration in central or peripheral nervous system, cardiopulmonary, or musculoskeletal function, obesity is a major risk factor for functional disability with advancing age. As a result of both these diseases and the treatments required for their control, obese older adults are far more likely to develop physical impairments or disabilities than are other older adults.

Obesity also makes it more challenging to obtain the needed level of care when disabled, all of which can lead to a deterioration in quality of life.

Given the increased risk of disability associated with obesity, controlled weight loss may be an appropriate therapeutic option for selected older adults. Short-term clinical trials in older people show that appropriate interventions can lead to moderate weight loss, resulting in improvements in CV risk factors (such as hypertension, insulin resistance, and metabolic syndrome) and other clinical outcomes. However, weight loss could produce more long-term adverse than beneficial results in some older adults. In fact, there is a strong association between weight loss in older adults and an increased risk of subsequent adverse clinical outcomes such as hospitalization and death. Even when trying to control for voluntary versus involuntary weight loss, there have been conflicting findings. Furthermore, when dietary restriction is the primary mechanism for weight loss, the loss of fat is accompanied by loss of both LBM (particularly skeletal muscle mass) and BMD. Although the percentage loss from each of these tissue compartments with dieting is the same in old and young adults, the adverse consequences could be much greater in older people who have lower functional reserves and higher fracture risk. This is particularly true for older people with sarcopenic obesity, as even a small further loss of muscle mass might cause significant functional impairment.

Thus, a primary focus of any weight loss intervention in older adults should be on preserving or improving LBM and BMD. The only approach to date that has proven successful in accomplishing this dual-purpose goal is the combination of an energy-restricted, normal to high-protein diet with moderate-to-intense exercise (also see Chapter 54). In obese older adults, diet and exercise together can lead to clinically meaningful improvements in key metabolic parameters, physical performance, self-reported physical function, and quality of life; the beneficial effects are greater and the loss of both BMD and LBM less than with either intervention alone. To attain these benefits, only moderate weight loss (in the range of 10%) is required. The target of the weight loss should be improvement in the target weight-related health conditions.

Although randomized, controlled trials provide strong evidence of benefit, little is known about how best to achieve these results with obese older adults in routine clinical settings. Efforts to increase physical activity and to decrease caloric intake are the best options for older adults, as surgical and pharmacological options are limited, usually untested in this population, and generally much riskier. Selective glucagon-like peptide

(GLP)-1 receptor agonists such as semaglutide (approved for weight loss by the Food and Drug Administration [FDA] in 2021) and most recently a dual GLP-1 receptor and glucose-dependent insulinotropic peptide agonist have been used effectively to promote weight loss in overweight adults both with and without type 2 diabetes. However, the safety and effectiveness of these agents to promote weight loss while preserving LBM, bone mass, and physical function in specific subpopulations of older adults remain to be determined. In the absence of relevant long-term clinical trial data on outcomes with weight reduction, advice on weight loss should be guided by symptoms related to obesity and its associated diseases, anticipated short- term health benefits, and the general level of health status of the patient.

To be considered a candidate for a weight loss program, an obese older adult needs to have a weight-related problem that is likely amenable to weight loss plus the motivation to commit to the necessary lifestyle changes that are required to meet program goals. In order to have any lasting benefits, changes in dietary habits and level of physical activity need to be maintained long-term. Such a vigorous program would likely require the individual patient to be relatively healthy.

Upon committing to a weight loss program, an older adult should undergo a careful medical evaluation, which should include a detailed history and physical examination as well as a very careful assessment of the potential risks and benefits of both exercise and diet. American College of Sports Medicine guidelines (see Chapter 54) should be used to assess the risks of exercise and need for more detailed diagnostic testing such as cardiac stress tests. Successful programs generally include an assessment of the individual’s insight, motivation, and readiness to make the necessary lifestyle changes. Using motivational interviewing or other techniques, the individual’s personal goals should be illuminated, and a personalized intervention strategy devised that includes short- and long-term goals and timelines. Support from or coparticipation by family and significant others can be critical to success.

Ideally, both the dietary and exercise interventions need to be consistent with the individual’s lifestyle, abilities, interests, and personal goals. When an established program is not available to which the individual can be referred, input and support from a multidisciplinary team of professionals is

crucial. Such a team may include a dietitian/nutritionist, physical therapist, nurse, physician, social worker, or other health professionals. The diet should include at least 1.0 g/kg/day of high quality protein, adequate micronutrients, and only moderate energy restriction (eg, 1100–1300 kcal/day) with the goal of 1 to 2 pounds of weight loss or less in a week. The exercise intervention should include a combination of endurance and progressive-resistance muscle strength training and be tailored to the individual (see Chapter 54 for details).

Once an obese older adult starts an exercise/weight loss program, the quality and frequency of follow-up support become crucial. Early in the intervention, frequent follow-up is often needed, but the intervals between contacts can be gradually extended once the individual demonstrates an acceptable trajectory of success. Follow-up can be accomplished by recurring clinic visits, phone calls, or any of a variety of electronic means. These follow-up visits can be used to monitor progress (eg, checking exercise and weight logs), provide ongoing support and assistance to deal with setbacks and barriers to success, and provide guidance in advancing exercise intensity or setting new goals. The level of involvement of a nurse or other appropriately trained health professional in the follow-up assessments needs to be determined based on the medical complexity of the participant.

Daily energy requirements per kilogram of body weight generally decline with age, dropping as much as 33% between the third and ninth decade of life. Male gender and chronic disease are associated with a greater rate of decline. However, a decrease in energy requirements with age occurs even among those who remain healthy, in part because of the age-related loss of muscle mass described above. Muscle is much more metabolically active than adipose tissue. As muscle mass decrease the ratio of fat to lean mass increases, leading to a greater drop in the basal or resting metabolic rate (RMR) than predicted by the decrease in total body mass. Since RMR generally accounts for 60% to 75% of TEE, the end result of the muscle loss is a significant decline in TEE, and thus energy requirements.

A second mechanism accounting for the decline in energy requirements with age is a decrease in physical activity. Energy expenditure of physical activity (EEA) generally declines with age to the same extent as RMR, accounting for about 15% to 35% of TEE in the majority of older adults.

However, EEA can range from 5% in those who are bedridden to 50% in highly active, physically fit older adults. Lifestyle plays a big role in determining EEA of older people, just as it does in those who are younger. Although the increased prevalence of chronic disabling diseases accounts for some of the decline in physical activity with advancing age, even healthy older adults tend to be more sedentary than younger individuals.

Some chronic conditions may result in an increased TEE, although this remains controversial. Examples include individuals with Alzheimer disease who constantly pace and individuals with a constant tremor. Even when an individual appears to be rather sedentary, their EEA may be greater than expected. For example, a patient with hemiparesis or amputation likely requires high levels of energy expenditure to complete basic activities of daily living due to low neuromuscular energy efficiency.

The usual decline in energy requirements with advancing age means that many older persons need to consume less food in order to maintain their weight and customary activity level. This places the older individual at risk of developing protein and micronutrient deficiencies, since requirements for other nutrients may not decrease as much as energy. Consequently, it is important that older individuals increase their activity level and change their diet to protein- and micronutrient-rich foods.

Because of the paucity of high-quality nutrition studies with adequate representation from older age groups, current recommendations for protein intake do not differentiate adults over the age of 65 from those who are younger. The latest (2005) version of the Recommended Dietary Allowance (RDA) for protein, released by the Food and Nutrition Board and the National Academy of Medicine, is 0.8 g/kg body weight/day for both men and women over age 19. However, some contend that the recommended protein intake for older adults should be 1.0 to 1.25 g/kg/day. Given the variability in estimates of protein requirements in older adults, it may not be possible to resolve this controversy until better measurement techniques become available.

Factors That Influence the Protein Requirements of Older Individuals The protein requirements of an individual can change with time, being

influenced by age, nonprotein content of the diet, activity level, medications, and health status. The energy content of the diet is particularly important. The protein intake required to maintain nitrogen balance increases the further total energy intake falls below 126 kJ/kg (30 kcal/kg). A negative energy balance usually precipitates a negative nitrogen balance, especially in individuals who are ill or who have a low level of activity. As a general rule, protein requirements increase with high levels of activity such as sustained high-intensity exercise. Thus, the role of a high protein diet, perhaps combined with resistance training, to prevent loss of LBM in older obese individuals during voluntary caloric restriction and increased physical activity to achieve weight loss (as described above) merits further study.

Many disease states and medications can induce a catabolic state for protein by altering the normal balance between protein synthesis and degradation. Older individuals who are both confined to bed and have an injury, infection, or another acute inflammatory condition are at particularly high risk of developing a profoundly negative nitrogen balance that can lead to a rapid loss of LBM, particularly skeletal muscle mass. High doses of corticosteroids can have a similar effect. The amount of protein that needs to be consumed in order to minimize loss of LBM and optimize recovery from such disease states is often difficult to determine. In general, older hospitalized patients who are acutely ill or recovering from major surgery or trauma warrant a protein intake of 1.5 g/kg of body weight/day or higher (also see discussion of Malnutrition below and Table 30-9) unless they have a condition that necessitates protein restriction such as renal or hepatic insufficiency. Whether one source of protein is better than another in meeting the nutrient needs of older adults is controversial. Although it is generally recognized that all older adults should consume a diet that provides adequate quantities of all essential amino acids, there is otherwise little consensus as to the importance of the dietary protein source.

Fat serves as a key source of energy and essential fatty acids as well as a vehicle for transporting fat-soluble vitamins. Even when obesity and elevated cholesterol or triglycerides are a concern, fat intake should not fall below 10% of total energy requirements in order to allow for adequate

absorption of fat soluble vitamins (A, D, E, K), and to ensure that the requirements for the essential fatty acids are met. There are two main types of essential fatty acids, the omega-6 series, derived from linoleic acid (eg, arachidonic acid and gamma-linoleic acid), and the omega-3 series, which could be derived from alpha-linolenic acid (from plant sources) or contained in krill oils or certain cold water fish (eg, eicosapentaenoic acid [EPA] and docosahexaenoic acid [DHA]); the omega-3 fatty acids obtained from fish are synthesized by microalgae, which the fish consume. The essential fatty acids are required for the synthesis of cell membrane phospholipids and eicosanoids, which include prostaglandins, leukotrienes, and hydroxy acids. Cell membrane phospholipids influence the biomechanical properties of the membranes and their membrane-bound receptors. The eicosanoids, derived predominantly from arachidonic acid and EPA, serve many functions including modulation of inflammation and host defenses. The eicosanoids made from omega-6s are generally more potent mediators of inflammation, vasoconstriction, and platelet aggregation.

Clinical deficiency of the essential fatty acids is rarely seen in adults since western diets generally include adequate amounts of these nutrients, and adipose tissue provides an additional reserve of 0.5 to 1 kg. When a deficiency does develop, it is usually a result of profound cachexia or extensive small bowel disease or necrosis and the inadequate provision of nutrition support. This is particularly true of the omega-6 fatty acids, which are abundant in many of the foods common to the average American diet including most vegetable oils, nuts, cereals, seeds, and legumes. In contrast, the average American diet may provide suboptimal amounts of omega-3 fatty acids. Although current recommendations call for the omega-3 derivatives of alpha-linolenic acid to be at least 0.2 % of total food energy, many nutritionists suggest higher intakes due to their purported beneficial effects on metabolism. Oils from a variety of cold water fish species including halibut, mackerel, herring, and salmon are potentially high in the omega-3 fatty acids. Currently, nutritional labeling does not indicate the amount of omega-3 fatty acids that is contained in fresh fish; farm-raised fish may have more or less omega-3 fatty acids than wild caught fish, depending on the food they are fed. Many omega-3 fatty acid supplements are available commercially, but these provide varying amounts of marine-based EPA and DHA. There is inadequate evidence that these supplements provide the same benefits as consuming fish. Alpha-linolenic acid, a precursor of EPA, is found primarily

in plant products such as soybeans, canola oil, flaxseed oil, and walnut oil. However, humans may be able to convert as little as 10% of alpha-linolenic acid to EPA.

The optimal fat intake for older adults needs to be determined on an individual basis. For example, reduced fat intake may be considered for a patient with CHD. However, the importance of dietary fat as a contributor to CHD risk after the age of 65 remains controversial. It is not known whether fat- and cholesterol-restricted diets have any beneficial effects in reducing CHD mortality in this age group. In fact, such diets may have detrimental consequences, especially in those who are having problems maintaining their weight. Therefore, it seems prudent to limit fat intake only in older individuals with CHD who otherwise would not be adversely affected by such dietary restrictions.

Increasing the ratio of monounsaturated and polyunsaturated fat to saturated fat, without changing total fat intake, may be beneficial in some situations. For this reason, some experts support the use of the Mediterranean-style diet, which promotes the use of olive oil, tree nuts, peanuts, fatty fish and other seafood, and white meat, and discourages intake of red and processed meats. Concern has also been raised about the use of partially hydrogenated fats rich in trans fatty acids, as these products may have an adverse effect on lipid metabolism. Although more study is needed, it is probably prudent to emphasize the use of natural fats derived from vegetable oils (predominantly monounsaturated), nuts, and fish while reducing those from animal products and avoiding foods containing trans fatty acids. However, this approach may not be applicable to frail older individuals, especially those who are losing weight involuntarily, have a BMI less than 20, or have diseases limiting their nutrient intake. Since fats have twice the energy content per gram as carbohydrates and protein, a diet high in fat may be necessary for such frail older individuals in order to meet their maintenance energy requirements or to replete deficits. Thus, restricting the types of foods these individuals consume may have detrimental consequences.

Recommendations for carbohydrate content of the diet are generally based on two considerations, the source of the carbohydrates and the energy requirements of the individual. Ideally, food sources should be rich in fiber

(see section on fiber content of diet below) and provide primarily complex carbohydrates rather than simple sugars. The amount of carbohydrates that should be included in the diet is usually determined by default. The energy, protein, and fat requirements of the individual are determined first.

Carbohydrate requirements are then determined by subtracting the amount of energy supplied by protein and fat from the total energy requirements. Since protein requirements represent approximately 15% of the total energy content of the diet and fat ideally should be less than 30%, carbohydrates usually represent 55% to 70% of the total. When carbohydrates are totally excluded from the diet, energy requirements of the body are partially met by the incomplete oxidation of fatty acids, which leads to ketosis and may cause lethargy and depression. Ketosis can also contribute to anorexia, which is part of the appeal of high-fat, low-carbohydrate weight loss diets. To prevent ketosis, at least 50 to 100 g of carbohydrates should be consumed each day.

Although fluid requirements do not change appreciably with age in adults, people over the age of 65 have a reduced ability to regulate their fluid intake and to limit urinary water losses. Thus, they are much more likely than young adults to become dehydrated (and hypernatremic) when their health status or environment changes. Regulation of water and sodium balance in older people, and recognition and management of dehydration/hypernatremia are reviewed in Chapter 39. Chronic disease and injuries that cause a deterioration of cognitive or physical function increase the risk of dehydration further by altering the perception of thirst, reducing the ability to express the desire for water, or diminishing the capability to access and drink adequate amounts of fluids. When an acute febrile illness occurs in an older individual who is already physically or cognitively impaired, life- threatening dehydration can develop rapidly. This scenario occurs with alarming frequency in nursing homes. The failure of many health care providers, family members, and personal aid assistants to recognize the risk factors and early warning signs of dehydration contributes to the danger that a frail older individual will become severely dehydrated. Many older adults themselves do not recognize their risks and may inappropriately restrict their fluid intake, sometimes as a method of controlling incontinence.

Care must be taken to prevent dehydration by recognizing those at highest risk, especially older individuals with cognitive and physical deficits,

swallowing problems, ongoing weight loss, diarrhea, fever, or poorly controlled diabetes, or receiving enteral feeding, diuretics, or laxatives. The minimum daily intake for inactive adults in moderate climates is estimated to be between 1 and 3 L/day; a reasonable target is roughly 30 mL/kg/day for most healthy older adults. Requirements increase with fever, activity, or prolonged exposure to an elevated environmental temperature (also see Chapter 39). Patients, family, and all health care staff, especially in nursing homes, need to be trained to recognize the importance of maintaining an adequate fluid intake at all times, and to carefully monitor intake if there is a change in mental status, activity level, or health status, or if fluid requirements increase, as may occur during heat waves.

Dietary fiber is derived from structural components of plant cell walls and consists of plant polysaccharides and lignin, which are resistant to digestion by intestinal enzymes. Many professional health organizations recommend a diet containing 20 to 35 grams of fiber a day or 10 to 13 grams dietary fiber per 1000 kcal consumed. Although dietary fiber may be associated with health benefits including a decreased rate of certain forms of cancer, diabetes, heart disease, and obesity, the average American diet is very low in fiber with consumption usually in the range of only 10 to 15 grams daily.

There are two general categories of dietary fiber: water-insoluble fibers, such as cellulose, hemicellulose, and lignin; and water-soluble fibers, such as gum and pectin. Each category of fiber has a somewhat different spectrum of beneficial effects. Both types lower the energy density of the diet. The added bulk also has a short-term satiety effect that helps control appetite and prevent overconsumption. Water-insoluble fiber has the further effect of holding water within the intestinal contents, which results in an increased fecal bulk, a decreased gut transit time, and a lower intraluminal pressure within the colon. These properties of water-insoluble fiber make it an important dietary component since it reduces constipation and may help prevent the formation of colonic diverticula. Sources of insoluble fiber include fruits, vegetables, dried beans, wheat bran, seeds, popcorn, brown rice, and whole grain products such as breads, cereals, and pasta. About

two-thirds to three-fourths of the dietary fiber in typical mixed-food diets is water-insoluble. There are many excellent web sites that provide tables listing the soluble and insoluble fiber content of foods (eg,

Water-soluble fiber increases the viscosity of intestinal contents, prolongs gut transit time, and decreases the rate of small intestinal absorption of carbohydrates and bile acids. These effects may have important physiologic implications that can be used to advantage clinically. By slowing the rate of carbohydrate absorption, a very high soluble-fiber diet can be effective in reducing the postprandial surge in the serum glucose, which may be beneficial in the treatment and prevention of diabetes. Through its effects on bile acid absorption, soluble fibers can lower total cholesterol and low- density lipoprotein (LDL) cholesterol by 3% to 10%. There is an inverse association between the total dietary fiber intake and the rate of fatal and nonfatal myocardial infarctions; several meta-analyses demonstrate that higher intake is also associated with decreased all-cause mortality. Most of these effects of soluble fibers were demonstrated using fiber concentrates.

Comparable amounts of fiber can be obtained from food sources, such as apples, oranges, pears, peaches, grapes, vegetables, seeds, oat and rice bran, dried beans, oatmeal, barley, and rye. Diets that are high in fiber from food sources also provide essential micronutrients and nonnutritive compounds such as xenobiotics, antioxidants, and phytoestrogens that may have important health-promoting consequences.

As a general rule, a diet rich in fresh fruits, vegetables, legumes, and whole grain products is recommended. As portrayed in the USDA Choosemyplate.gov, this should include two cups of fruit, 2 1/2 cups of vegetables, and 6 ounces of grains each day (Figure 30-6). Since most fruits and vegetables contain less than 2 grams/serving total fiber and most refined grain products contain less than 1 gram/serving, legumes, whole grains, and cereal brans should be substituted for other foods whenever possible in order to increase the amount of both kinds of fiber. Supplementing the diet with any of the commercially available concentrated fiber sources may be necessary, especially in frail older people. Concentrated sources of dietary fiber may also be helpful in the treatment of chronic constipation when a limited variety of food is available or the amount of food consumed is inadequate. A large increase in fiber over a short period of time may result in bloating, diarrhea, gas, and general discomfort. It is important to add fiber

gradually over a period of several weeks to avoid abdominal problems. Fiber supplements should always be taken with adequate fluid in order to avoid worsening constipation.

The Food and Nutrition Board of the US National Research Council developed the dietary reference intakes (DRIs), which updated the earlier RDAs for vitamins and minerals. The DRIs include separate intake recommendations for adults from age 51 through 70, and for adults older than 70 years. There are not enough scientific data to calculate requirements for all micronutrients, and any person with a medical disorder may need more or

less than the DRI for some nutrients. Table 30-5 lists the recommended intakes for various vitamins, as well as the recommended tolerable upper limits (ULs) intake. Intakes of micronutrients that are lower than the UL usually pose little risk for toxic side effects in healthy people. The UL allows patients and health care workers to understand possible risks if large amounts of vitamins and minerals are consumed. Understanding and consuming the DRI for vitamins and minerals reduces the risk for classic deficiency disorders (eg, scurvy, pellagra, beriberi, etc), but the ideal intake of vitamins and minerals needed for optimum health, which may be higher than the DRIs or ULs, remains controversial. Changes to the DRIs are often contentious, and they can have major medicolegal and financial implications for fortified foods and the supplement/health food industry.

TABLE 30-5 ¦ ADULT DIETARY REFERENCE INTAKES AND TOLERABLE UPPER LIMITS FOR SELECTED VITAMINS AND MINERALS

Many older adults, including those who are healthy and living independently as well as those who are frail, ill, or institutionalized, are at risk for micronutrient deficiencies. Several population-based nutritional surveys demonstrate that community-dwelling older adults commonly consume as little as 50% of the DRIs for many vitamins. These findings reflect the fact that even healthy adults do not consistently consume recommended amounts of fortified dairy products, fruits, and vegetables. Risk factors for poor intake, adverse drug-nutrient interactions, and nutrition-related diseases all increase as a function of age, and clinical (and subclinical) deficiencies of vitamins and minerals become more likely, particularly once frailty and the need for institutionalization occurs. The micronutrients most commonly deficient include vitamins C, D, E, B12, thiamine (B1), and folic acid, and the

minerals calcium, magnesium, and zinc. Because of this, many nutritionists recommend that older adults add a daily, iron-free, general vitamin and mineral supplement supplying the DRI for most micronutrients, although evidence in support of benefit from this recommendation is lacking. Studies

of multivitamin supplementation in noninstitutionalized people have found no benefit in reducing CV or cancer risk. It also remains unclear as to whether intakes of individual micronutrients above the DRI in selected populations are beneficial. High intakes of some micronutrients (such as vitamins A, D, and pyridoxine) are well known to cause toxicity, which may be so subtle and nonspecific that the harmful effects may not be easily diagnosed. High supplemental intakes of other vitamins or provitamins (such as vitamin E and ß-carotene) that had been thought to be risk-free have now been associated with adverse health consequences. Thus, older adults should be counseled not to exceed the tolerable ULs (see Table 30-5) for vitamin intake and to disclose all vitamin and mineral supplement use whenever medications are reviewed by health professionals. Vitamin and mineral supplementation should not substitute for an overall program of healthy nutrition (eg, high fruit, vegetable, and whole grain intake and reduced simple sugar and saturated and trans-fat intake).

Low serum vitamin B12 levels become more common with aging, and about 10% to 15% of older adults have vitamin B12 deficiency. Pernicious anemia,

an autoimmune disorder causing decreased gastric intrinsic factor production, is a rare cause of deficiency in an older adult. Cobalamin deficiency in older adults is more commonly due to malabsorption of cobalamin in foods; usually due to atrophic gastritis and hypochlorhydria (Table 30-6 lists multiple other causes). Supplemental B12 in crystalline

form is not affected by atrophic gastritis and continues to be well absorbed. Stomach acid helps remove the vitamin from food and make it bioavailable. Disorders that interfere with enterohepatic absorption (such as ileal disease or surgery) will lead to deficiency more rapidly than low intake because the high efficiency of enterohepatic vitamin B12 reabsorption will be impaired,

Vitamin B12 deficiency can present clinically with two relatively independent disorders. There is a hematologic disorder that causes macrocytosis and anemia. And there is a neurologic disorder that can cause a

lesions, including loss of vibration and position sense, sensory ataxia, limb weakness, orthostatic hypotension, and plantar extensor responses; and neuropsychiatric symptoms. These signs and symptoms of vitamin B12

deficiency are nonspecific and common in many older adults with comorbid disorders. When there are several possible causes for the neurologic signs and symptoms, vitamin B12 supplementation is usually accompanied by

disappointing, small measurable neurologic or behavioral improvement. The older the patient is and the more profound the signs and symptoms are, the less likely is the recovery. However, some patients may respond, especially if deficiency is relatively recent. Since patients with more severe hematologic signs often have less neurologic impairment, and vice versa, it is important to consider vitamin B12 deficiency even if the patient lacks

macrocytosis and anemia. Thus, screening older adults for vitamin B12 deficiency should be considered, and supplementation of all deficient patients is recommended.

pg/mL) have measurable biochemical abnormalities, including elevated methylmalonic acid (MMA) (> 270 nmol/L) levels, which improve with supplementation. Although these patients often appear to be asymptomatic, it is probable that borderline serum vitamin B12 levels represent an early

preclinical deficiency state. If this is the case, current laboratory norms for vitamin B12 are too low, since they may not identify patients with early deficiency. Secondary tests for low B12 status are also nonspecific and rarely

useful; for example, MMA may also be elevated with renal failure, and homocysteine levels are also affected by folate and vitamin B6 status.

guidelines are presented in Table 30-7. Intramuscular or oral replacement is most common; alternative formulations (such as nasal gels) are more costly and have not been rigorously tested. There is no scientific basis for prescribing vitamin B12 supplementation as a general tonic, and it is not

recommended. Oversupplementation of vitamin B12 is not recommended and may be associated with increased mortality.

TABLE 30-7 ¦ EVALUATION AND TREATMENT OF VITAMIN B12 DEFICIENCY IN OLDER ADULTS

Folate deficiency is associated with general malnutrition (particularly that accompanying alcohol abuse) or with specific folate antagonists, such as methotrexate, phenytoin, sulfasalazine, primidone, phenobarbital, and triamterene. Like vitamin B12 deficiency, it can present as a megaloblastic

macrocytic anemia. Although measures of both vitamin B12 and folate status are often included in the evaluation of macrocytosis, low folate is a rare cause of this disorder. Folate supplementation alone may improve the

ongoing neurologic disorder of vitamin B12 deficiency, and may even cause a more rapid neurologic/cognitive deterioration. However, in B12-deficient patients with restored normal B12 status, high folate intake is associated with

protection from cognitive impairment. There are very rare case reports of neuropathy associated with folate deficiency. Slowed mental processing, including poorer performance on mental status testing, and depressive symptoms (particularly impaired motivation and social withdrawal) have been described in patients with folic acid deficiency. It is uncertain if folate deficiency has an association with major depression, and whether genotype testing for mutations in the MTHFR (5,10-methylenetetrahydrofolate reductase) gene or supplementation with the more expensive L-methylfolate (which crosses the blood–brain barrier more easily) improves response to treatment-resistant depression. Fortification of grains with folic acid began in the United States in 1998 (to reduce the incidence of neural tube defects in developing fetuses). Consumption of a diet rich in fruits and vegetables, along with fortified grains, continues to be recommended as the best source for folic acid, but folate in supplements is more bioavailable.

Folate status may be assessed by measuring serum folate if dietary intake (diet or vitamin supplementation) has not been recently changed or with erythrocyte (red blood cell [RBC]) folate levels if there has been a recent change in diet (as after hospital admission). Homocysteine levels can be elevated in folic acid deficiency, but may also be increased with renal insufficiency, and with vitamin B12 or B6 deficiency.

Vitamin D plays a critical role in maintenance of normal bone health (see Chapter 51). The complex physiology of vitamin D, its relationship to calcium and bone metabolism, nutritional and other causes of vitamin D

deficiency, and the clinical features and treatment of vitamin D deficiency are all covered in Chapter 97, so are not addressed here. While vitamin D has been postulated to have multiple physiologic functions beyond those related to bone and calcium metabolism, these effects are controversial.

Routine screening of healthy older adults with 25(OH)D levels is controversial and expensive. The Choosing Wisely initiative does not recommend routine vitamin D screening, and the US Preventive Services Task Force (USPSTF, 2021) reports that there are no studies directly evaluating benefits or harms of screening. Vitamin D supplementation does not prevent or improve nonskeletal conditions, including mood disorders, cognitive decline, diabetes mellitus, adiposity, fatigue, osteoarthritis, chronic pain, cardiovascular disease (CVD) (including atrial fibrillation), strength, or colorectal adenomas. There is weak evidence that supplementation may prevent viral illnesses and asthma exacerbations. High-dose vitamin D does not benefit BMD, muscle function, muscle mass, or falls, and may increase harms (falls, death, and hospitalization). Based on multiple studies, the USPSTF (2018) recommends against D supplementation to prevent falls in community-dwelling older adults. It also found Insufficient Evidence to recommend vitamin D and calcium supplementation to prevent fractures in community-dwelling postmenopausal women and asymptomatic men without osteoporosis or vitamin D deficiency.

From adolescence onwards, both men and women should consume between 1000 and 1200 mg of elemental calcium daily, unless there are unique nutrition requirements. Many older adults consume far less than this amount. In addition, calcium absorption declines with age and varies depending on dietary source. The UL for calcium intake is 2000 mg/day for people over age 50. The important role of calcium intake in management of osteoporosis is covered in Chapter 51.

A cup of milk or yogurt contains about 300 mg of calcium. Green vegetables contain some calcium, but they also contain other phytochemicals that interfere with calcium absorption. Therefore, calcium bioavailability from vegetables may be limited. Because of dietary limitations or other factors, many older adults are unable to consistently obtain the recommended intake of calcium from natural sources and may need to take calcium supplements. Some brands of orange juice and candy now contain added

calcium, which can add to dietary sources of this element. Calcium is also available in pill form. Calcium carbonate is least expensive but should be consumed with food (although high-fiber foods may reduce absorption somewhat). Some other formulations, such as calcium citrate, are better absorbed but may cost more, or have less calcium per pill. Calcium supplements can increase constipation in some individuals. Persons who develop calcium oxalate kidney stones should not drastically limit their calcium intake from foods, as dietary calcium can bind with and reduce food oxalate absorption and decrease risk of stone formation. Observational studies have identified a possible association between calcium supplementation and increased risk for CVD. Until this issue is clarified, emphasis should be placed on maximizing calcium intake from food sources.

Although numerous vitamins have been linked to cognitive decline with advancing age and to the pathogenesis of Alzheimer disease, most of this evidence is from observational studies. For example, there are associations between dietary intake of foods high in carotenoids and a diminished risk of cognitive impairment. These findings highlight the potential importance of maintaining a well-balanced diet, but do not provide evidence of cognitive benefit of using supplements containing any vitamin.

There is a growing body of evidence that nutrition plays an important role in CVD prevention. Diets that are lower in saturated fat, contain poly- and monounsaturated fatty acids, and include an abundance of fruits and vegetables are associated with a reduced risk of CVD events. A number of dietary regimens fall into this category including the Mediterranean-style diet (described in the Fat and Cholesterol section), which reduced major CVD events in persons at high risk.

Antioxidants have also been promoted as protective for CVD and cancer. The rate of cardiac death may be lower in people who consume a diet rich in the antioxidant vitamins and minerals, particularly vitamins E and C, and carotenoids. These findings are difficult to interpret as diets rich in

antioxidants are also higher in fiber and lower in cholesterol and saturated fat; and people who consume large amounts of fruits and vegetables, or who take vitamin supplements, often have healthier lifestyles. Meta-analyses of randomized clinical trials for primary prevention of CVD have not confirmed a beneficial effect of any vitamin, antioxidant, or fish oil supplement. In fact, increased morbidity or mortality was found with the use of supplemental ß- carotene, vitamin E, and selenium; high supplemental vitamin E may increase risk for hemorrhagic stroke and all-cause mortality. High-dose omega-3 fatty acid supplementation, including mixed EPA-DHA, carboxylic acid formulations, and icosapent ethyl (IPE) formulations, have produced mixed but generally negative results on improving CVD, bone health, falls risk, nonvertebral fractures, and infection rates, and are not yet recommended.

There is currently no convincing evidence that any vitamin, mineral, or antioxidant supplementation prevents cancer. It is very likely that people with cancer or other serious illnesses will try alternative therapies, including megavitamin and mineral supplements, and herbal or folk remedies. Although it is generally thought that the toxicity of antioxidant vitamins and most B vitamins is low for intakes below the UL, there is increasing evidence of potential harms. Some of this evidence has come from intervention trials which have reported an increased incidence of lung cancer in high-risk patients treated with ß-carotene supplements, an association between selenium supplementation and skin cancer, and an increased incidence of prostate cancer in men who took vitamin E. These risks should be discussed proactively with patients so that they can have the best information available to make their decisions and toxic side effects can be prevented. Tolerable ULs should not be exceeded.

Evidence to support a protective effect of individual vitamin and mineral supplements on age-related eye diseases is conflicting. The Age-Related Eye Disease Study (AREDS) found a slight reduction in progression (not prevention) of age-related macular degeneration (AMD) using a combination of higher-dose vitamins C and E, ß-carotene, zinc, and cupric oxide. In the AREDS2 study, the addition of omega-3 fatty acids (DHA and EPA) and/or lutein and zeaxanthin (macular xanthophylls) and removal of ß-carotene did not decrease AMD progression. The AREDS2 supplementation also did not

reduce CVD risk in the older adult participants. Observational studies have identified an association between dietary antioxidant content and a lower risk of age-related cataracts. However, there is also no evidence that regular high doses of antioxidant vitamin and mineral supplements are effective in preventing cataracts.

The risk of developing one or more nutritional disorders increases with age. Prevention and early intervention are the best approaches to keeping older individuals optimally nourished because many forms of malnutrition, particularly protein and energy undernutrition, are very difficult to reverse. Providers should routinely screen their older patients to determine if they have or are at risk of developing nutritional problems, at least annually and whenever there is a change in the patient’s health. Like other screening instruments, the nutritional screen should use simple criteria, be relatively easy to complete, have relatively low attendant costs, and provide a valid assessment of nutritional risk with a reasonable degree of sensitivity and specificity. Examples of screening instruments include the Malnutrition Screening Tool (MST), Malnutrition Universal Screening Tool (MUST), and the Mini-Nutrition Assessment (MNA). Individuals identified by the screen to be at risk of having or developing nutritional disorders should be scheduled for a more in-depth assessment.

For the initial screening assessment, older individuals who have experienced a recent deterioration in their socioeconomic or health status should be considered at high risk. Since many older individuals facing financial hardship do not volunteer this information, it is important to assess whether financial resources are inadequate to meet living expenses, including the purchase and preparation of an appropriate variety and quantity of foods. Food insecurity is an important issue for some older adults (see Chapter 21). When the older person is dependent on others for meal preparation or feeding assistance, caregiver neglect and other forms of abuse can pose serious threats and often require careful vigilance to identify. The nutritional screen should also assess psychological stressors, particularly the loss of a spouse or other family members. Older individuals should always be evaluated for depression. Alcohol and drug abuse are serious but frequently

unrecognized problems that can cause a variety of nutritional disorders; screening tools include the CAGE Alcohol Questionnaire and Alcohol Use Disorders Identification Test (AUDIT).

The list of medications that can adversely affect nutrient intake is very long (see Table 30-2). Any drug that is being taken, including over the counter (OTC), herbals, and folk medications, should be considered suspect when anorexia or weight loss occur. Many drugs produce subtle side effects that older individuals may tolerate when feeling well. However, these same side effects, which may include alterations in appetite, taste sensation or salivary secretion, nausea, constipation, diarrhea, or a depressed sensorium, can contribute to the development of anorexia during periods of ill health.

Swallowing problems can also adversely affect nutrient intake (see Chapter 31). Besides choking or coughing while eating or drinking liquids, the signs and symptoms may be far more subtle and can include only food avoidance. Older patients who are hospitalized are at very high risk of developing nutritional deficits prior to discharge. Prolonged bed rest, acute inflammation, and inadequate nutrient intake, which are common during hospitalization, rapidly lead to the depletion of both lean and total body mass, placing the older patient at high risk for subsequent mortality. For this reason, any acute hospitalization should be recognized as a nutritional risk factor.

A careful weight history, possibly the most important component of the nutrition screen, should be obtained from all older patients. Since patients often provide inaccurate accounts of their weight history, prior weights from the medical record may be useful. A weight loss of 5% or more within the prior 3 months or 10% or more within the prior 6 months to 3 years should be considered indicative of a potentially serious nutritional problem unless the weight fluctuation can be ascribed with certainty to alterations in fluid balance, such as those with heart failure or on hemodialysis. There is a clear and direct correlation between the amount of weight that is lost and increased risk of subsequent mortality (Figure 30-7), even if older individuals state that they voluntarily lost the weight. Voluntary weight loss in frail older adults has the same adverse implications as involuntary weight loss, likely because few older individuals successfully lose weight volitionally and keep it off while healthy. Thus, “voluntary” weight loss is the result of underlying pathology in many older individuals.

FIGURE 30-7. The relationship between the amount of weight that was lost in the prior year and the estimated risk of mortality within the subsequent year. Based on a study of 750 patients age 65 and older discharged from an acute care hospital.

As part of the general physical examination, a weight and height should be obtained. If significant kyphosis or scoliosis is present, the patient’s estimate of peak adult height can be utilized for current height. From the weight and height measurements, the patient’s BMI and weight as a percentage of usual weight can be calculated. Since poor oral health may contribute to the development of nutritional problems, a careful oral examination is indicated.

Anthropome trics Neither BMI nor the skinfold measurements are good measures of total body fat mass if there is significant intra-abdominal fat accumulation, as often occurs with advanced age. Waist circumference and the waist-to-hip ratio are reasonably useful indicators of abdominal fatness, as defined earlier.

Albumin A random serum albumin, interpreted without regard to clinical context, has low sensitivity and specificity and only limited clinical utility as a nutritional indicator. While albumin synthesis decreases by 30% to 50% after only 24 to 48 hours of protein and energy deprivation, there may be little change in the serum albumin concentration even after a much more

prolonged period of fasting in an otherwise healthy individual. During periods of inadequate nutrient intake, a decreased rate of albumin degradation and mobilization of albumin from the extravascular space may contribute to the maintenance of a normal serum albumin concentration. For these reasons, albumin is not a very sensitive screening test for early stages of nutritional deterioration. Conversely, a low albumin concentration has low specificity as an indicator of protein-energy undernutrition. Acute and even chronic subclinical inflammation and other disease conditions are usually the primary contributors to the development and maintenance of a low serum albumin. Although in healthy individuals serum albumin has a half-life of approximately 20 days, during periods of acute physiologic stress (such as major surgery or sepsis), the serum concentration can decline by up to 30 g/L within a few days. This effect on the albumin concentration is probably mediated by cytokines that are believed to increase vascular permeability to albumin. The concentration of albumin is normally much greater within the intravascular compared to the extravascular space (35–50 g/L compared to ~ 10 g/L). With inflammation-induced changes in vascular permeability, there is a rapid loss of the normal concentration gradient between the intra- and extravascular space and an apparent sequestration of albumin in extravascular sites. These same cytokines also suppress albumin synthesis and may trigger an increased rate of albumin degradation with a resultant drop in the serum concentration to 25 g/L or less. Prolonged hypoalbuminemia can also develop in association with advanced liver disease (cirrhosis), severe congestive heart failure, nephrotic syndrome, and protein-losing enteropathies. When these conditions are not present, a persistently low serum albumin probably represents ongoing inflammation and is associated with a high risk of adverse outcomes, including death. The independent effect of nutritional deprivation on low albumin is unclear. Since it is not currently possible to differentiate the effects of inflammation from those of nutritional deprivation, a low albumin indicates only that the patient is at risk for being undernourished, and for increased morbidity and mortality. Serum albumin does not increase rapidly with refeeding and should not be utilized as an indicator of the adequacy of nutritional support.

Prealbumin Although it has limited specificity as a nutritional indicator, serum prealbumin may respond to changes in nutrient intake if there is no persistent inflammation or other active disease processes that are keeping the serum levels suppressed. Despite its name, prealbumin is not a precursor to

albumin. Its more descriptive name is transthyretin because it transports both thyroxine and retinol (vitamin A). In health, prealbumin has a half-life of 2 to 3 days and a much smaller volume of distribution compared to albumin. Like albumin, prealbumin is a negative acute-phase reactant. In response to systemic inflammation, liver production declines and the serum concentration drops rapidly. Low levels are also found in association with end-stage liver disease, iron deficiency, and nutrient deprivation. Renal failure and high- dose steroid therapy are associated with elevated prealbumin concentrations. Because of its relative short half-life, prealbumin is more sensitive to changes in nutrient intake and disease activity than is albumin. The serum concentration begins to drop after 3 to 5 days of very low nutrient intake in an otherwise healthy individual and can decline by 50% or more after a major physiologic insult. In the latter case, the nadir value is usually reached within 3 to 5 days and corresponds to the period of maximal negative nitrogen balance. With resolution of the inflammatory process, the serum concentration will climb rapidly to the normal range if nutrient intake is adequate. A rising prealbumin correlates with positive nitrogen balance.

This fact may be used to advantage to assess the adequacy of nutrition support. Failure of the serum concentration to increase by at least 20 mg/L in 1 week is considered an indication of inadequate nutrient intake and/or ongoing inflammation and should prompt a careful assessment of the patient and the nutrient regimen being employed.

Although frequently difficult to obtain, a detailed nutrient and caloric intake assessment is often the most critically needed part of the nutritional assessment. In the outpatient setting where both over- and undernutrition may be a concern, a 24-hour recall or a 3-day food intake diary can be effective tools for estimating nutrient intake and identifying where dietary modifications need to be made, especially if a dietitian or comparably skilled health care provider gives the patient and the family adequate instructions on how to collect the needed data. The employment of more accurate methods of measuring nutrient intake is often especially necessary within hospitals and nursing homes.

Unfortunately, many older patients are maintained throughout their hospitalization on nutrient intakes that are far less than their estimated maintenance energy requirements. Contributing to the problem, the attending

health care team often overestimates how much food the older patient is consuming. In one study, over 20% of nonterminally ill older hospitalized patients had an average daily nutrient intake while hospitalized that was less than 50% of their maintenance energy requirements. This lack of adequate nutrient intake was associated with a significant deterioration in protein- energy nutritional status by discharge and a sevenfold increased risk of mortality. Low nutrient intake may be an even more widespread problem within nursing homes. Only by carefully monitoring each older individual’s nutrient intake during their institutional stay can this problem be recognized. However, resources are often not available to support monitoring efforts.

Within the hospital setting, older patients who are not recovering as rapidly as expected, have been placed on clear liquids or nothing by mouth for more than 24 hours, have a persistently low serum prealbumin, or are unexpectedly losing weight, should have their nutrient intake measured each day until they resume an adequate diet. A dedicated team of appropriately trained staff members may be needed to perform this daily nutrient intake assessment, since accuracy often suffers when the regular nursing and dietary staff performs this function. Within nursing homes, any resident experiencing an acute illness, change in mental status, loss of weight, or decline in functional status should have their nutrient intake monitored in a similar fashion.

Protein-energy malnutrition (PEM) is present when insufficient energy and/or protein is available to meet metabolic demands. PEM may develop because of poor dietary protein or caloric intake, increased metabolic demands, or increased nutrient losses. Proposed clinical criteria from the Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition to diagnose adult malnutrition are listed in Table 30-8.

TABLE 30-8 ¦ CLINICAL CHARACTERISTICS RECOMMENDED FOR THE DIAGNOSIS OF ADULT MALNUTRITIONA

Prevalence data, relying on a variety of measures of nutritional adequacy, suggest that deficiencies in macronutrients (protein energy) and micronutrients (vitamins and minerals) are very common among older adults. National survey data indicate that 40% to 50% of noninstitutionalized older adults are at moderate to high risk for nutritional problems, and up to 40% have diets deficient in three or more nutrients. Prevalence estimates in selected populations over age 65 indicate that 6% to 15% of older persons seen in outpatient clinics, 12% to 50% of hospitalized older persons, and 25% to 60% of older persons residing in institutional settings have one or more nutritional inadequacies—with PEM being the most common. Physical and psychosocial factors that may lead to inadequate nutrition were discussed earlier and are listed in Table 30-1.

As discussed earlier in this chapter, energy intake declines with age, attributable in part to decrements in LBM and physical activity that often accompany aging. A still greater reduction in caloric intake to levels that may be below daily requirements has been a consistent finding of nutritional surveys conducted among community-dwelling older adults. The National Health and Nutrition Examination Survey (NHANES III) found that the mean daily energy intake of persons age 70 and older was approximately 1800 kcal/day for men and 1400 kcal/day for women, and more than 10% of older adults reported consuming less than 1000 kcal/day. Even if this limited energy intake met the caloric needs of less-active older adults, it is unlikely that all noncaloric nutrient needs (vitamins and minerals) would be met unless the diet was extremely diverse and rich in nutrients. Although

micronutrient deficiencies are common when PEM is moderate to severe, it is the PEM that tends to have the greater clinical impact. Poor nutritional status and PEM are associated with altered immunity, impaired wound healing, reduced functional status, increased health care use, and increased mortality. Despite the confounding effect of coexisting nonnutritional factors, poor nutrition remains an independent source of increased morbidity and mortality after adjustment for nonnutritional factors.

PEM may occur as a consequence of inadequate intake alone (eg, starvation) or in association with disease-activated physiological mechanisms that affect body metabolism, composition, and appetite (ie, cachexia). In the former (primary caloric deficiency state) the body adapts by using fat stores while conserving protein and muscle, and the resulting physiologic changes are often reversible with resumption of usual intake and activity. Cachexia is a complex metabolic syndrome that is associated with elevated inflammatory cytokines (eg, TNF-a and IL-6) and increased protein and muscle degradation that may not be mitigated or reversed by refeeding. Although cachexia is usually associated with specific chronic disease conditions (eg, cancer, renal failure, chronic obstructive pulmonary disease [COPD]), this state may develop in older persons without obvious underlying disease.

Despite its clinical importance, malnutrition is often missed clinically. Effective management of frail or ill older adults mandates an evaluation of nutritional status to better allow for early recognition of PEM and consideration of appropriate interventions. Assessment of nutritional status by standard anthropometric, biochemical, and immunologic measures can be complex, as both nutrient intake and non-nutrition-related factors can affect these parameters (see preceding section on Assessment of Nutritional Status). The close monitoring of body weight, a readily obtainable measure that reflects imbalance between caloric intake and energy requirements, is a simple and reliable way to screen for malnutrition, particularly in the outpatient setting. Weight loss of 5% or more of usual body weight over 6 to 12 months is associated with increased morbidity and mortality in the outpatient setting, and so is the degree of weight loss that should prompt investigation.

In the hospital setting, where acute illness or injury often coexists with inadequate intake, alterations in nutritional parameters associated with PEM may develop rapidly. Elevated levels of inflammatory mediators appear to be responsible for the greater losses in LBM and the rapid declines in albumin that often accompany PEM in physiologically stressed patients.

While serial weight measures remain clinically relevant, early detection and correction of PEM in acutely ill hospitalized patients is enhanced by determination of dietary intake relative to metabolic requirements. Although registered dietitians often provide this information, all members of the clinical care team should be aware of dietary intake and can readily estimate caloric and protein requirements using formulas presented in Table 30-9.

Biochemical and immunologic measures (eg, albumin, prealbumin, transferrin, and lymphocyte counts) can provide prognostic information, but their lack of specificity limits their utility as markers of PEM. An effective assessment of nutritional status requires synthesis of information provided from the dietary history, physical examination, and biochemical data. There are no definitive criteria for classifying degrees of PEM. However, when weight loss exceeds 20% of premorbid weight, serum albumin is less than 21 g/L, transferrin is less than 1 g/L, and total lymphocyte count is less than 800/ µL, PEM is generally considered to be severe.

TABLE 30-9 ¦ ESTIMATION OF DAILY ENERGY AND PROTEIN NEEDS

Initial management of patients with PEM and/or weight loss should include a thorough evaluation to identify underlying causes, and if found, to aggressively attempt to correct potentially remediable factors. In the acute care setting the cause(s) of malnutrition are often readily evident, although depression may be a contributing factor that is frequently overlooked. In contrast, reasons for poor nutrition and weight loss among community- dwelling older persons may be multiple and not as readily discernible.

malabsorption disorders), and cancer are the three most common causes of involuntary weight loss in older adults when a single predominant cause is present (Table 30-10). When cancer is the cause of weight loss, the diagnosis is rarely obscure. Most diagnoses are readily made after standard evaluations that include a careful history and physical examination and basic screening tests, with additional tests only as directed by signs and symptoms. If the initial basic evaluation is unrevealing, as will occur in roughly 25% of cases, it is best to enter a period of “active surveillance” rather than pursue more extensive undirected testing. A diagnostic algorithm (Figure 30-8) focusing first on verifying actual weight loss (patients may inaccurately report a history of weight loss) and then on whether caloric intake is adequate can help guide an appropriate work-up.

TABLE 30-10 ¦ DIAGNOSTIC SPECTRUM OF INVOLUNTARY WEIGHT LOSS

General considerations Older persons who are not meeting their protein and caloric requirements through oral intake should be considered for nutritional support. Table 30-11 outlines approaches to nutritional support and factors to consider in deciding whether to pursue specific interventions. The urgency for nutritional interventions relates to the degree of protein-calorie depletion at the time of diagnosis coupled with the expected magnitude and duration of inadequate nutrition. In the hospital setting, clinicians must consider that patients may have been suffering from PEM for some time prior to admission. Therefore, delay in instituting nutritional support while waiting for improved intake should be avoided. One approach is to intervene if a patient has a 5- to 7-day period of severely limited intake or for weight loss more than 10% of preillness weight in a hospitalized patient. However, attempts should be made to prevent PEM rather than wait for this degree of PEM to develop because weight loss and undernutrition are associated with worse clinical outcomes, and recovery of lost LBM is often difficult. This is particularly important in severe stress states (eg, sepsis, major injury) where protein catabolism can lead to LBM losses that approach 0.6 kg/day. In support of early intervention when the development of PEM is likely, a trial of enteral nutrition among patients with major injury found that early (within

24 hours) enteral feeding had clinical benefits over tube feeding started later in the course of hospitalization.

TABLE 30-11 ¦ APPROACHES TO IMPLEMENTING NUTRITIONAL SUPPORT

Patie nt preference The effect of the planned intervention on the patient’s quality and/or quantity of life should be addressed before proceeding with nutritional support. Although nutritional support interventions may improve weight and other nutritional parameters, evidence demonstrating their ability to improve clinical outcomes is still limited, particularly when PEM is associated with serious (eg, critically ill intensive care unit [ICU] patients) or irreversible underlying disease (eg, cancer). While efforts to improve nutrition, even in patients with serious underlying disease, are often warranted, late in the course of disease appropriate palliative care may include, if not mandate, discontinuing such efforts. Determination of the care preferences of the patient is a critical component of the decision-making process. Patient and family counseling prior to implementing nutritional

support should include a review of the interventions being considered and their potential for adverse, as well as beneficial, effects. Figure 30-9 provides an algorithm to help guide nutritional support decisions.

Nonpharmacologic approaches Although it is uncommon for hospitalized older persons with PEM to be able to increase their food consumption sufficiently to correct their nutritional deficits, trials of strategies to improve voluntary intake are reasonable for stable patients with mild PEM (no definitive criteria exist, but parameters consistent with mild-moderate PEM include weight 85%–90% of premorbid weight, albumin 25–30 g/L, transferrin 1.5–

2.0 g/L, total lymphocyte count 800–1200/µL). As previously outlined, underlying causative or contributing condition(s) to PEM should be sought, identified, and addressed. Strategies to help overcome anorexia and improve oral intake include assessing and meeting food preferences, providing frequent small meals and snacks, use of fortified and flavor-enhanced foods, providing company at meals and feeding assistance as needed, and minimizing dietary restrictions. A dietitian may aid greatly in these efforts.

The role for high-protein, high-calorie oral nutritional supplements is not clear. While meaningful clinical benefits may occur in malnourished older adults, the effects are less clear in persons with dementia or other

progressive illnesses, particularly in the outpatient setting. A Cochrane Library review concluded that oral nutritional supplements produce modest (2% on average) weight gain, may reduce mortality in undernourished individuals, and may reduce hospital complications, but evidence for functional benefits or reduced length of hospital stay is lacking. As the greatest mortality impact was found in hospitalized malnourished patients age 75 or older who received high-calorie supplements, it seems reasonable to recommend such supplements in older hospitalized patients with, or at high risk for, PEM. Higher-calorie “plus” variety nutritional supplements (1.5–2.0 kcal/mL) are preferred over standard (1 kcal/mL) formulas, as costs are only slightly higher. Furthermore, because they deliver higher calorie content per milliliter ingested, patients do not need to drink as much volume to improve caloric intake. Supplements should be provided between, rather than with, meals as this appears to result in less compensatory decreases in food intake at mealtime, thereby more effectively increasing total daily caloric intake. However, even if total caloric intake is only marginally improved, the provision of energy from nutritionally dense supplement sources may be beneficial due to improved protein and micronutrient intake.

A standard multivitamin supplement should also be considered for all older adults with PEM. Although study results are not consistent, some have demonstrated that improving micronutrition with multivitamins, particularly in malnourished or at-risk persons, may improve clinical outcomes (eg. infection rates). Increased physical activity is an important adjunct that can help maintain LBM and improve appetite, thereby leading to improved caloric intake and functional status.

Drugs Pharmacologic approaches to stimulate appetite and promote weight gain can be considered on an individual basis with the knowledge that the few agents (megestrol acetate [MA], dronabinol, cyproheptadine) that may improve intake in some patient populations (eg, cancer, human immunodeficiency virus, anorexia nervosa) have not been shown to be effective in older adults and may cause serious side effects. Further, the weight gain that has been observed with these agents has usually been small, disproportionately fat mass, and not associated with improved function, quality of life, or decreased morbidity and mortality. MA increases risks of thrombotic events, fluid retention, and mortality. The American Geriatrics Society Beers Criteria lists both MA and cyproheptadine as medications to be avoided in older adults. Dronabinol has not been carefully studied in

older adults and at best has shown limited promise in small nonrandomized trials conducted in nursing home patients. If initiated, MA may not have a demonstrable effect on appetite for several weeks, but if no effect is seen by the eighth week, MA should be discontinued. If positive effects are demonstrated without significant side effects, MA may be continued for up to 12 weeks. Treatment for more than 8 to 12 weeks can suppress the adrenal– pituitary axis, resulting in adrenal insufficiency and insufficient response to acute stressors. MA also appears to blunt the beneficial effects of progressive resistance exercise, consistent with an undesirable glucocorticoid-like catabolic effect.

If depression is felt to be a contributing factor to poor intake, a trial of therapy is usually warranted. Selective serotonin reuptake inhibitors (SSRIs) are first-line antidepressant agents that may improve appetite by improving depression. Mirtazapine leads to more weight gain than SSRIs, but it is not clear that mirtazapine has a significant advantage over other antidepressants when weight loss is a predominant presenting sign in a depressed older adult. There is no high-quality evidence to support the use of mirtazapine for weight gain in the absence of depression.

Anabolic agents Anabolic hormones (eg, growth hormone [GH], testosterone, oxandrolone) have received considerable attention in the search to find strategies to help preserve or increase LBM in patients with malnutrition and weight loss. Although adequate nutrition is essential for patients with weight loss, a physiologically stressed catabolic patient may lose significant LBM despite aggressive nutritional support (and the weight gain that does occur with nutritional support and appetite stimulants may be primarily fat and water). GH has generally failed to demonstrate benefits on muscle mass or muscle strength in older adults, even in association with resistance training. The use of GH in intensive care and congestive heart failure patients has also yielded disappointing results with evidence of increased mortality. The cost, need for injection, and potential side effects of GH (eg, arthralgias, edema, insulin resistance, tumor growth) further limits its clinical role. Testosterone increases muscle protein synthesis mass and strength, and improvements in functional outcomes have been observed in small, controlled trials in selected male populations (eg, older men after knee replacement surgery, deconditioned older men on a Geriatric Evaluation and Management unit).

Although testosterone might be considered in men with documented clinical hypogonadism (see Chapter 97), its role in the setting of malnutrition and/or cachexia remains to be clarified, especially in light of known safety concerns (in particular CV). Oxandrolone, a synthetic testosterone derivative with an increased anabolic to androgenic effect ratio, has shown some utility for patients with weight loss in association with AIDS/HIV or burns, and preliminary data also suggest benefit in patients with COPD. This agent can cause hepatitis, hirsutism, and fluid retention, and is contraindicated in patients with breast or prostate cancer. Selective androgen receptor modulators (SARMs), for example enobosarm, have the potential to provide desirable anabolic effects on muscle and bone without androgenic effects elsewhere, but these agents are still under study and not yet available clinically. Other anabolic agents that are under study include myostatin inhibitors and ghrelin analogues. Myostatin is expressed in skeletal muscle and inhibits muscle protein synthesis and promotes fibrosis. Blocking these effects may provide a novel approach to prevent muscle loss and promote muscle growth. Ghrelin is an endogenous GH secretagogue that increases appetite and has anabolic properties that can lead to increases in LBM. Anamorelin is an oral ghrelin analogue that has shown promise in patients with cancer-associated anorexia/cachexia. It remains under study and is not commercially available.

Physical activity Efforts to increase physical activity are an important adjunct to any nutritional intervention as positive effects of exercise include enhanced appetite and improved functional status. The benefits (and safety) of exercise in older populations are reviewed in Chapter 54.

Enteral nutrition (EN) is defined as the nonvolitional delivery of nutrients by tube into the GI tract. EN should be considered for patients with PEM, or at high risk for it, who cannot meet their nutritional requirements through oral intake. However, specific indications regarding if and when to provide EN are not clearly established, and patient prognosis and preference are critical factors that must be taken into account. EN requires a functional GI tract and is contraindicated in patients with bowel obstruction, inadequate bowel surface area, major upper GI bleeding, GI ischemia, or intractable vomiting

or diarrhea. Purported benefits of enteral tube feedings relative to parenteral nutrition (PN) include the maintenance of GI structure and function, more physiological delivery of nutrients, less risk of overfeeding and hyperglycemia, and lower costs. Although some of these advantages may be more theoretical than actual, EN is preferred when GI function is adequate. EN and PN should not be considered mutually exclusive. For patients unable to fully meet their nutritional requirements through EN, a mixture of PN and EN is preferable to PN alone.

Efficacy EN can improve prognostically important intermediate nutritional parameters but the effects of EN on clinical outcomes (eg, functional status, medical complications, mortality) are unclear owing to limited and/or mixed data. EN is often not initiated until advanced PEM is present, which is a clear impediment to the potential positive effects of nutritional therapy. There is prospective clinical trial evidence that EN can improve both nutritional parameters and clinical outcomes (eg, length of stay, infectious complications, and mortality) in older undernourished hip fracture patients.

Further study is needed to determine which older hospitalized patients might benefit most from aggressive nutritional support. In the interim, sufficient rationale exists to consider EN for patients who are undernourished or at high risk for undernutrition and cannot meet their nutritional needs with oral intake.

Tube placement The route selected for tube feeding depends on the anticipated duration of feeding, the potential for aspiration, and the condition of the gastrointestinal tract (eg, esophageal or gastric obstruction). Nasogastric (NG) or nasointestinal tubes provide the simplest approach for patients requiring relatively short-term EN (< 30 days). Patient comfort is often problematic, and tolerance is best when a small-diameter, soft feeding tube is used rather than a standard large-bore NG tube. The use of longer specialized feeding tubes also allows the tube to reach beyond the pylorus into the distal duodenum or jejunum (ie, beyond the ligament of Treitz), which is the preferred site of placement for patients who have delayed gastric emptying or are at high risk for aspiration. Methods to promote passage of the tube past the pylorus when postpyloric feeding is desired include ensuring adequate tube length, having the patient lie on their right side, prescribing erythromycin or metoclopramide, or using endoscopic or fluoroscopic guidance to position the tube. However, postpyloric feeding can be a challenge to maintain as even endoscopically placed tubes may migrate

back into the stomach. After placement, the desired tube position should be verified radiologically before starting feedings and the tube should be marked at its exit point to help identify if subsequent movement occurs.

Percutaneous tube placement (gastrostomy, gastrojejunostomy, jejunostomy) is indicated when long-term tube feeding is anticipated (> 4 weeks). Percutaneous placement of gastrostomy tubes (G-tubes) can be performed either endoscopically or under radiographic guidance. The risks of major complications with either procedure are generally low, but infection, hemorrhage, and peritonitis have each been reported at rates of 1% to 3%. Placement of feeding tubes directly into the jejunum may be required for patients with abnormal or inaccessible stomachs (eg, gastrectomy, duodenal obstruction). Although direct jejunostomy tube (J-tube) placement can be accomplished using percutaneous methods, a J-tube traditionally requires an open surgical procedure and is often placed at the time of laparotomy when the need for prolonged nutritional support is anticipated.

Tube feeding is associated with an increased incidence of aspiration. However, most aspiration pneumonias are the result of difficulty handling endogenous (oropharyngeal or gastric) secretions rather than aspiration of material introduced through the tube. Thus, it is not entirely surprising that although postpyloric feeding tube placement is generally advised in older and sicker patients, the reduction in the incidence of pneumonia is small.

Formula selection Adult enteral formulas fall into one of the following categories: standard, concentrated, predigested (previously called elemental or semi-elemental), and disease-specific. All consist of varying mixtures of protein (often casein), carbohydrate (often cornstarch), and fat (usually vegetable oils), and most do not contain lactose. Formula variability includes nutrient composition, nutrient density, osmolarity, fiber content, and cost (cost tends to be substantially higher for disease-specific specialty formulas, and up to 10-fold higher for critical care and predigested specialty formulas). Isotonic standard formulas with caloric densities of 1.0 to 1.2 kcal/mL are usually the initial products of choice. Higher caloric density formulas (1.5–2.0 kcal/mL) may be useful when volume restriction is paramount (eg, in patients with renal failure) but their higher viscosity increases the risk of tube clogging and their higher osmolarity may be less well tolerated if delivered rapidly via tubes placed beyond the pylorus.

There is no evidence that routine supplementation of EN with fiber prevents diarrhea, but supplemental fiber may be tried if patients receiving EN are

having problems with diarrhea or constipation. Predigested formulas differ from standard EN because their carbohydrates are less complex and proteins have been hydrolyzed to short-chain peptides. Although they are promoted for patients with diminished ability to digest nutrients, it is uncommon for patients to be incapable of digesting and absorbing standard formulas unless they have significantly impaired gastrointestinal function (assuming appropriate adjustments are made in rates of feedings, osmolality, and fiber content).

Disease-specific/specialty formulas are available for patients with renal failure, liver failure, diabetes mellitus, pulmonary disease, gastrointestinal dysfunction, and critical illness. However, as costs are usually substantially higher and no clear clinical benefits have been consistently demonstrated, disease-specific formulations are not routinely recommended. Renal formulas, which are low in electrolytes and dense in calories, do have a place in renal failure patients who have need for fluid and/or electrolyte restrictions. These formulas may be useful before dialysis but are not necessary for most patients once on dialysis. Formulas have been developed for diabetic patients but use of cheaper standard formulas with adjustments in glucose control regimens as necessary is adequate for most diabetic patients. Formulas for pulmonary patients have higher fat and lower carbohydrate content based on the now known erroneous rationale that this alteration in fuel source reduces carbon dioxide production. Clinical studies have failed to show any benefit to support the use of pulmonary EN formulations.

Hepatic formulas have specific amino acid mixtures (high in branched chain, low in aromatic amino acids) that are less likely to cause or exacerbate hepatic encephalopathy. They are only indicated when, despite appropriate medical therapy, hepatic encephalopathy limits the delivery of adequate protein to a patient with liver disease.

A number of specialty formulations have been designed for critically ill patients. Some of these products are enriched with glutamine (an amino acid associated with improved nitrogen balance and gut barrier function as well as immune-modulating effects when delivered parenterally), arginine (a conditionally essential amino acid associated with improved nitrogen balance and immune function), and/or other immune modulators (eg, antioxidants, selenium, omega-3 fatty acids). However, meta-analyses have not shown convincing clinical benefits and a large trial of “immunonutrition” in an ICU population found that early provision of glutamine or antioxidants

did not improve clinical outcomes, and glutamine was associated with increased mortality. Pending further study, use of these products in EN formulas is not recommended.

Administration guidelines After desired tube placement location is confirmed, tube feeds (TFs) can be started at a rate of 10 to 30 mL/hour. Two basic approaches to advancing TF flow rates are: (1) maintain a lower “trophic” feeding goal of 25% to 30% of estimated needs for 6 days before increasing to target rate; versus (2) advance TF rate to goal as quickly as tolerated over 24 to 48 hours. The American Society for Parenteral and Enteral Nutrition favors the latter for patients who are severely malnourished or at high nutritional risk while noting that EN was better tolerated in mechanically ventilated ICU patients (eg, less vomiting, reduced use of prokinetic agents) and clinical outcomes were similar when feeding rates were kept low (10– 30 mL/hour, roughly 30% of target rate) for 6 days before increasing by 25 mL/hour every 6 hours as tolerated to target rate. In non-ICU settings feeding rates can be advanced 25 mL/hour every 6 to 12 hours based on individual tolerance, until target rate is reached. Routine checking of gastric residual volume (GRV) lacks benefit and is no longer recommended unless abdominal distension, abdominal pain, nausea, or change in clinical status occur. An evaluation for remediable factors (eg, medications, high fat-content formulas) should be conducted if GRV exceeds 250 mL, and feedings should be held if GRV exceeds 500 mL. Once daily requirements are reached, further adjustments to deliver nutrients primarily at night can allow more freedom of movement during the day. Nocturnal feeds probably offer little benefit in terms of decreased satiety and improved intake during the day relative to continuous feeds. Intermittent bolus gastric feedings without a pump offers convenience advantages but generally should be avoided in persons with delayed gastric emptying and those at high risk for aspiration.

As all feeding products consist of no more than 70% to 80% water, they are unable to meet basal free-water requirements of roughly 30 mL/kg per day. Most patients require additional water beyond the routine water flushes that occur with medication and TF administration to avoid tube clogging.

Attention must also be paid to water and electrolyte requirements as they will need to be increased with excess losses due to diarrhea, high urinary output, or increased insensible losses. For patients with fever, an additional 300 to 400 mL of water is needed for each degree centigrade of temperature elevation. Monitoring of weight and electrolytes can help detect any

necessary adjustments, with additional free-water needs given in divided boluses three or four times a day.

Risks and complications Proper consideration of whether to proceed with EN entails an understanding of common adverse effects (Table 30-12). NG tubes are often not well tolerated, with agitation and self-extubation being particularly common among patients with cognitive impairment or delirium. Self-extubation may lead to consideration of physical or chemical restraints, but such restraints are not justified to prevent NG tube self-extubation alone. Also, EN in actual practice often involves delayed and inadequate nutritional support because of frequent problems with tubes (eg, self-extubation, plugging) or GI intolerance (eg, high residuals, bloating, diarrhea). These factors may explain why attempts to provide EN to older persons are often abandoned after only a short course of therapy. Some have advocated for an early switch to PN, or starting with PN, particularly if patients are confused or delirious and the expected duration of therapy is short (1–2 weeks). If longer-term support is likely, early use of percutaneous gastrostomy tubes, which tend to be better tolerated by uncooperative or confused patients, may be considered (along with a reevaluation of overall patient care preferences and intervention goals before proceeding with this more invasive approach).

TABLE 30-12 ¦ ADVERSE EFFECTS OF ENTERAL NUTRITION AND MANAGEMENT APPROACHES

Pulmonary aspiration is a relatively common complication of EN, but unless aspiration causes an overt clinical event (eg, aspiration of a large volume), it is not clear that aspiration causes untoward clinical outcomes such as higher rates of pneumonia. Nonetheless, strategies to reduce aspiration are generally advised. Patients with gastric retention, decreased gag reflex, and altered levels of consciousness are at increased risk for aspiration, and mechanically ventilated patients should not be considered protected by the presence of an endotracheal cuff. The risk of aspiration can

be reduced as outlined in Table 30-12. EN-related GI issues and their management are also presented in Table 30-12. When significant diarrhea occurs, infectious causes (particularly Clostridium difficile) must first be excluded. Metabolic abnormalities related to tube feedings include high potassium and phosphorous requirements in the first few days after nutritional support is started because of extracellular to intracellular shifts that accompany nutrient utilization, particularly among very malnourished patients (“refeeding syndrome”). Fluid retention can occur in older adults with impaired renal or cardiac function. To minimize these problems, monitoring protocols should include frequent evaluation of GI tolerance, daily weights, and daily monitoring of glucose and electrolytes until stable.

Increased problems with tube clogging often occur when more viscous higher-calorie formulas and medications (especially fiber and calcium supplements) are passed via small-bore (smaller than no. 10 French) catheters. Tube maintenance with regular water flushing every 4 to 8 hours for patients on continuous feeds, and before and after the delivery of intermittent TFs or medications (with 30 mL warm water) can reduce clogging problems. When possible, medications should be given by mouth rather than by feeding tube. If clogging occurs flush with 30 to 60 mL warm water, or a solution containing pancreatic enzymes. Cola or cranberry juice flushes have not been shown to be any more effective than water for resolving occlusions, and when used their dried residuals can narrow the lumen of the tube and contribute to clogging. Another common mechanical problem is the replacement of a gastrostomy or jejunostomy tube that has fallen out. Feeding tube fistula tracts are generally not well established for at least 1 to 2 weeks after placement (and often substantially longer given malnutrition’s adverse effect on wound healing). Tubes that come out early (in the first 2–3 weeks after placement) require replacement by the original specialist. If the fistula tract is well established, patients or care providers should be able to gently replace tubes that have fallen out. Delay in doing so for more than 6 to 12 hours risks spontaneous closure of the tract. However, feeding should not be resumed until proper tube placement is radiologically confirmed.

PN, the delivery of nutrients by vein, should be considered to prevent the adverse effects of malnutrition in patients who are unable to obtain adequate

nutrients by oral or enteric routes (ie, EN is not possible or effective). However, specific indications regarding if and when to institute PN, as well as the utility of PN once instituted, have not been clearly delineated. In general, the decision to institute PN depends on the severity and expected course of the underlying disease(s) and the severity of preexisting and anticipated undernutrition. For critically ill patients who are adequately nourished on admission and have contraindications to EN, guidelines from the Society of Critical Care Medicine and American Society for Parental and Enteral Nutrition recommend against PN during the first week as early PN likely increases the risk of infections and other complications without conferring benefit. Conversely, in the situation where EN is not possible and the patient is severely malnourished or at high nutrition risk on admission, these same guidelines recommend consideration of PN as soon as possible after ICU admission. They also advise supplemental PN be considered after 7 to 10 days (but not before) for patients unable to meet more than 60% of energy and protein requirements by the enteral route alone. Decisions to institute PN require careful consideration of the patient’s clinical condition and prognosis, clinical judgment about the patient’s ability to tolerate undernutrition, and insight regarding patient care needs and preferences.

Efficacy The European Society for Clinical Nutrition and Metabolism concluded that PN can reduce morbidity and mortality in geriatric patients, but the evidence that PN improves clinical outcomes in older adults is not robust. There are limited data on beneficial effects of PN in the following settings: perioperatively in patients with GI cancers; in patients undergoing major elective surgery who are severely malnourished (generally when weight loss exceeds 10%–15% and serum albumin level is < 33 g/L, or, in the absence of weight loss, if albumin is < 28 g/L); and in bone marrow transplant recipients, malnourished critically ill patients, and patients with short bowel syndrome. Overall, there is still a paucity of studies and many unanswered questions about the efficacy and safety of PN in older adults.

Intravenous access Total parenteral nutrition (TPN), the delivery of all required nutrients by vein, requires the use of hypertonic solutions that can only be tolerated when delivered into large venous vessels, preferably into the superior vena cava. Because peripheral veins are limited to solutions containing lower concentrations of amino acids and dextrose (< 10%

dextrose), peripheral parenteral nutrition (PPN) alone usually cannot deliver nutrients in sufficient quantity to meet all requirements. Although the infusion of lipids can improve energy delivery and vessel tolerance to PPN, its role in PN is extremely limited given the uncertain clinical benefits of short-term PPN and the ease of obtaining central venous access for TPN. Short-term TPN in the hospital setting is preferably delivered via a peripherally inserted central catheter (PICC). PICC lines offer reduced risks of central placement complications (eg, pneumothorax, inadvertent arterial puncture, and hemorrhage) and may have a reduced risk of infectious complications compared to subclavian or internal jugular venous catheters. Tunneled central venous catheters (eg, Hickman or Groshong catheter) are generally preferred over PICCs for long-term TPN (eg, home TPN) owing to lower infection rates. Regardless of the placement method used, proper line position needs to be confirmed by x-ray before initiating TPN.

TPN composition Standard TPN solutions contain carbohydrate (dextrose), protein (amino acids), electrolytes, vitamins, minerals, and trace elements. Lipid emulsions (traditionally soybean or safflower oil with egg phospholipids) may be infused separately or added to the mixture. Although clinicians should have a basic knowledge of usual TPN formula composition (Table 30-13), PN should be initiated and monitored by a team (usually physicians, nutrition specialists, and pharmacists) with an advanced understanding of factors such as nutrient metabolism and solute compatibility. Clinicians should also be aware that electrolyte requirements are highly variable and often require adjustments as they are influenced by the patient’s underlying diseases (eg, heart failure, renal dysfunction) and factors such as renal or GI fluid losses.

TABLE 30-13 ¦ “AVERAGE” TPN FORMULA COMPOSITION AND PARAMETERS FOR DAILY VITAMIN, MINERAL, AND ELECTROLYTE REQUIREMENTS

The optimal proportions of fat and carbohydrate to meet energy needs are controversial. All standard formulas contain hypertonic glucose (10%–70% dextrose before mixing), but because diabetes and glucose intolerance are so common in older people, slow upward titration in delivery rates is

necessary. Aggressive glucose monitoring and treatment is important, as hyperglycemia is associated with increased infection risk and worse clinical outcomes in critically ill patients. Glucose infusion rates should not exceed 5 mg/kg/min (about 500 g/day for a 70-kg person on continuous TPN) because the rate at which stressed patients can metabolize glucose as energy is limited. Overfeeding with glucose can lead to not only hyperglycemia, but also increased carbon dioxide production and the conversion of excess glucose calories into fat (which requires energy and contributes to fatty liver changes).

Lipids in the form of 10% to 20% fat emulsions are added to TPN as a source of concentrated energy and to supply essential fatty acids. Delivery of fat emulsions two to three times a week is usually sufficient to prevent essential fatty acid deficiency. Fat emulsions are isotonic and are generally well tolerated, but patients occasionally develop hyperlipidemia and, less frequently, have allergic reactions (usually to the egg phospholipid component). Increasing the proportion of energy supplied by fat can reduce hyperglycemia and carbon dioxide production, but fat delivery should not exceed 2.5 g/kg/day (or 50%–60% of nonprotein calories) to avoid possible adverse consequences associated with fat overload. The fat overload syndrome is characterized by hyperlipidemia with diffuse fat deposition that can cause organ and reticuloendothelial system dysfunction and increased risk of sepsis. Newer lipid emulsions that contain omega-3 fatty acids (eg, mixtures that include fish oil as well as olive oil) may have anti- inflammatory properties that could be beneficial during critical illness, but to date evidence is inadequate to recommend their routine use.

Formula delivery Infusion rates usually start at 25 to 50 mL/h and are increased every 8 to 12 hours as metabolic status allows until fluid and nutrition goals are met. At some institutions, carbohydrate, fat, and protein TPN components are mixed together into a single bag (total nutrient admixture or 3-in-1 formula), which may have cost and convenience benefits compared to traditional TPN administration of dextrose and amino acids (2-in-1) with separate intravenous (IV) fat emulsion infusions. In most circumstances, daily TPN volumes are infused continuously over the full 24 hours. This allows slower delivery of carbohydrate (which can help reduce hyperglycemia), and the continuous flow may decrease the risk of catheter occlusion while avoiding interruptions that might lead to hypoglycemia. Shorter infusion schedules with brief periods off TPN (cyclic TPN) are occasionally

desirable, but this is more of an issue for long-term TPN in the home care setting. Because TPN formulas (especially the lipid component) can suppress appetite, it may be desirable to reduce or hold lipid emulsions for a few days to help improve oral intake prior to planned discontinuation of TPN.

Patient monitoring and complications Older persons receiving TPN should be monitored closely (Table 30-14), with adjustments made in frequency of monitoring depending on the patient’s acuity and stability. Table 30-15 details common complications and their prevention and/or treatment.

Correction of dehydration and volume depletion can most readily be accomplished with standard IV fluids, which can be infused separately or added to TPN bags for convenience. Fluid overload can be managed by using higher concentrations of macronutrients to limit total volumes infused, with diuretics added as needed. Although insulin can be added directly to TPN solutions to help control hyperglycemia, it is best to give insulin separately until caloric delivery and glucose control are stabilized. IV insulin is preferred over subcutaneous insulin owing to the latter’s potential for erratic absorption in malnourished patients. Infection and volume depletion need to be considered if hyperglycemia is a persistent problem. As with EN, potassium and phosphate must be monitored closely because they may drop precipitously after initiating TPN in malnourished patients. In most cases, electrolyte requirements stabilize within 1 week. The relative amounts of chloride (which can lead to metabolic acidosis) and acetate (which can be metabolized to bicarbonate and lead to metabolic alkalosis) can be adjusted as needed depending on the patient’s acid–base balance.

TABLE 30-14 ¦ GUIDELINES FOR MONITORING PATIENTS ON TPN

Infection of the access line is uncommon in the first 72 hours, so early fevers are usually a result of other causes. The risk of infection can be reduced by following optimal insertion techniques and providing aseptic vigilant catheter care. The line site should be monitored daily for erythema, tenderness, or discharge. The increased rates of sepsis that have been observed in some trials of TPN (and which possibly diminished the potential for TPN trials to demonstrate improved clinical outcomes) may have been related to overfeeding and hyperglycemia. Avoidance of hyperglycemia (in particular glucose levels > 200 mg/dL) may decrease the risk of TPN- associated infections. Liver abnormalities that can occur with TPN include fatty liver with elevated liver function tests (often occurs early, likely related to carbohydrate overfeeding, generally benign/reversible) and cholestasis (tends to occur later, after 3+ weeks). EN, even in small amounts, may reduce problems with cholestasis.

Efforts should be made to transition to EN or oral intake as soon as feasible. As tolerance to EN improves, the amount of PN energy should be reduced and PN should be discontinued when EN or oral intake is providing more than 60% of energy requirements.

Comorbidity Responses to nutritional support may vary substantially owing to heterogeneity in underlying disease states associated with PEM (particularly the presence and severity of inflammatory/catabolic states). Limited data on the interaction between nutritional support and specific comorbid conditions and care settings include the following:

Hip fracture As many as half of all older patients who present with hip fractures are malnourished. Undernutrition may directly contribute to hip fracture events via increased presence of osteoporosis, increased risk of falls due to reduced LBM and strength, and reduced fat to “cushion” a fall. Nutritional intervention, primarily with oral nutritional supplements, improves energy balance and reduces complications and hospital length of stay following hip fracture. Accordingly, attention to nutrition is an important aspect of post hip fracture care, particularly in undernourished patients. As nasogastric feedings are not well tolerated after hip fracture and do not improve mortality, EN should be reserved for patients with more severe levels of malnutrition with poor intakes not responsive to oral supplementation.

Chronic obstructive pulmonary disease Prevalence estimates of malnutrition in patients with COPD range from 20% to 70%. Causes are likely multifactorial and include increased inflammatory activity, higher metabolic rate due to work of breathing and diminished intake due to dyspnea, chronic sputum (can alter taste), flattened diaphragm (may contribute to early satiety), and medication side effects (eg, adverse GI effects). Nutritional support (most often with oral supplements) has beneficial effects on a wide range of COPD outcome measures that include anthropometrics, immune function, muscle strength, respiratory function, and quality of life. Given their relative low cost and potential for benefit, nutritional support should be considered for all patients with COPD and evidence of PEM.

Nursing home Very high prevalence rates of PEM and weight loss have been documented in nursing home patients, likely because conditions associated with reduced intake are so common (see earlier discussion and Table 30-1), In this setting, simple interventions such as fortified foods, high-calorie snacks, nutritional supplements, and assisted feeding, can improve nutritional parameters and help stabilize weight. Although it is not clear that improvements in nutritional parameters translate to improved clinical

outcomes, such interventions may enhance quality of life and are reasonable and appropriate for most nursing home residents.

Dementia Use of TFs in patients with advanced dementia is not advised. Tube feeding patients with advanced dementia does not improve nutritional status, decrease pressure sores or infections, reduce aspiration problems, or improve functional status or survival. Potential adverse effects of TFs in these patients include increased risk of aspiration, discomfort and complications from tube placement, agitation driving increased use of physical and chemical restraints, worsening pressure ulcers from increased urine and fecal output, and diminished quality of life from decreased interaction at mealtime and loss of gustatory pleasure from food intake. The lack of demonstrable benefits combined with considerable potential for harm led the American Geriatrics Society to advise clinicians not to recommend percutaneous feeding tubes in patients with advanced dementia and instead focus on oral-assisted feeding with food as the preferred nutrient.

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Demographic changes related to aging necessitate that clinicians have the resources to address eating and swallowing difficulties present in older adults. The capacity to effectively and safely eat or swallow is one of the most basic human needs and also can be a great pleasure. Therefore the loss of this capacity can have far-reaching implications. Many would argue that swallowing is one of the cardinal behaviors needed to sustain life. The process of swallowing requires orchestration of a complex series of psychological, sensory, and motor behaviors that are both voluntary and involuntary. Dysphagia refers to difficulty swallowing that may include oropharyngeal or esophageal problems. More specifically, there may be difficulty in oral preparation for swallowing and/or moving material from the mouth to the esophagus and from the esophagus to the stomach.

Although age-related changes and comorbidities place older adults at risk for dysphagia, an older adult’s swallow is not inherently impaired.

Presbyphagia refers to characteristic changes in the mechanism of swallowing of otherwise healthy older adults. Clinicians need to be able to distinguish among dysphagia, presbyphagia, and other related diagnoses such as globus to avoid misdiagnosis and overtreatment of dysphagia. Older

adults can be more vulnerable and, with additional stressors such as acute illness and certain medications, they can cross over from having a healthy older swallow (presbyphagia) to experiencing dysphagia. This chapter reviews the normal swallowing process and presbyphagia, as a healthy aging evolution, dysphagia outcomes, multidisciplinary approaches to diagnosing and managing dysphagia, and rehabilitation strategies for dysphagia care.

Dysphagia prevalence depends on the specific population sampled, with community-dwelling and more independent individuals having rates near 15%. Upward of 40% of people living in institutional settings, such as assisted living and nursing homes, are dysphagic. Given the projected increases in the geriatric population over the next several decades, the prevalence of dysphagia is expected to increase substantially. With a greater number of individuals in assisted-living facilities and nursing homes, there is a compelling need to address dysphagia not only in ambulatory and acute care settings but also in long-term care settings.

The consequences of dysphagia vary from social isolation because of the embarrassment associated with choking or coughing at mealtime to physical discomfort (eg, food sticking in the throat) to potentially life-threatening conditions. The more serious sequelae include dehydration, malnutrition, and both overt and silent aspiration, precipitating pulmonary complications. For the purposes of this chapter, aspiration is defined as the entry of material into the airway below the level of the true vocal folds. Silent aspiration refers to the circumstance in which a bolus comprising saliva, food, liquid, medication, or any foreign material enters the airway below the vocal folds without triggering overt symptoms such as coughing or throat clearing. Both overt and silent aspiration occur more frequently in older adults and may lead to pneumonitis, pneumonia, exacerbation of chronic lung disease, or even asphyxiation and death.

Dysphagia is an independent risk factor for the development of aspiration pneumonia. The reported prevalence of dysphagia in older patients hospitalized for pneumonia ranges from 55% to 86%. Dysphagia is also an independent risk factor for hospital readmission due to aspiration and nonaspiration pneumonia in patients 70 or older discharged from an acute geriatric unit. Dysphagia is an independent risk factor for malnutrition as well.

Signs of bolus flow abnormality in dysphagia, using instrumental assessments (videofluoroscopy and fiberoptic endoscopic evaluation of swallowing [FEES]), include (1) the duration, direction, and completeness of bolus flow; (2) the duration and extent (range) of anatomic structural movements; and (3) the relationship between bolus flow and structural movements as well as between physiologic and anatomic parameters such as pressure generation and muscle/fat structure. Bulbar innervated swallowing mechanisms may provide targets specific for novel treatment paradigms aimed at improving swallowing function. Other clinical outcomes of dysphagia have become important end points in assessing interventions that aim to make it possible for patients to eat and drink adequately and safely.

pneumonitis, overt aspiration pneumonia, and other forms of pulmonary damage are monitored. Nonetheless, it has been difficult to attribute mortality directly to dysphagia because it is often a secondary rather than a primary diagnosis.

Dysphagia profoundly influences quality of life (QOL). Patients with swallowing difficulties, especially those who relinquish oral eating, manifest significant changes in psychosocial status, functional status, and emotional well-being. Eating and drinking are social events that relate to friendship, acceptance, entertainment, and communication. As such, major adjustments in the process of feeding and eating can lead to distressing responses such as shame, anxiety, depression, and isolation. Practical dysphagia-specific, comprehensive, QOL measures are available. By monitoring functional outcomes in clinical practice, physicians and other health care providers may be able to better assess and adjust their treatment of dysphagia.

Swallowing is an orchestrated activity that balances the competing behaviors of ingestion, speaking, and breathing. Approximately 30 oral and pharyngeal muscle pairs and multiple nerves must perform precisely on cue so that the upper aerodigestive tract is reconfigured from a mechanism that channels air for breathing and speaking (Figure 31-1) to a food-propelling mechanism that accomplishes ingestion (Figure 31-2). The four morphologic regions serving these purposes are the oral cavity, pharynx, larynx, and esophagus.

Of these, the first three collectively are termed the upper aerodigestive tract because they also serve the airway-dependent functions of respiration and speech production. In humans, with our upright posture, it is the adjacent position of the anatomy for breathing to the anatomy for food passage that facilitates gravitational influences on food to flow into an unprotected airway. Such anatomy and physiology require precision to satisfy the delicate balance between swallowing physiology and breathing—each a life- sustaining function that must occur during cessation of its counterpart. Thus, a basic understanding of the relationship between the anatomic components and the functional interaction of this mechanism is essential to an understanding of normal swallowing and the effects of age and age-related diseases on it.

FIGURE 31-1. Aerodigestive tract channeling air for breathing from the nose and mouth through the open larynx into the lungs and back up and out. For speaking, air is channeled similarly, but the vocal folds vibrate to produce voice. (Modified with permission from Weihofen D, Robbins J, Sullivan PA. The Easy to Swallow, Easy to Chew Cookbook . New York, NY: John Wiley and Sons; 2002. Illustration ©2002 by Kathryn M. Kleckner.)

FIGURE 31-2. Aerodigestive tract reconfigured from an air channel to a food-propelling mechanism during swallowing. The tongue propels food into the throat; the epiglottis covers the larynx, which is the airway entrance; and the vocal folds close to protect the trachea and lungs from foreign material. (Modified with permission from Weihofen D, Robbins J, Sullivan PA. The Easy to Swallow, Easy to Chew Cookbook . New York, NY: John Wiley and Sons; 2002.

Swallowing is an integrated neuromuscular process consisting of a combination of volitional and relatively automatic movements. Although normal swallowing is usually conceptualized as a continuous sequence of events, the process of deglutition has been conveniently described as occurring in two, three, or four phases or stages. Moreover, the system engaged in swallowing can be divided into two basic structural subsystems, horizontal and vertical (Figure 31-3), that mirror the direction of bolus flow and the potential for gravitational influence on it.

FIGURE 31-3. The oropharyngeal swallowing mechanism can be divided into two basic structural subsystems, horizontal and vertical, that mirror the direction of bolus flow. UES, upper esophageal sphincter. (Adapted with permission from Robbins J. Normal swallowing and aging. Semin Neurol. 1996;16[4]:309–317.)

Horizontal subsystem The oral cavity components comprise the horizontal subsystem, which handles the initial, largely volitional, processing and transport phases of swallowing—the swallow preparatory phase and the oral transport phase. The swallow preparatory phase is characterized by food acceptance, containment, and manipulation. The lips and the buccal musculature act in complex patterns, varying the size and shape of the oral opening to allow acceptance and/or containment of food within the oral cavity. The process of chemically changing the material requires that numerous labial and lingual glands secrete into the oral cavity an enzyme- rich fluid that maintains and lubricates the mucosa and is directly incorporated into the food. Textural manipulation of food and the mechanical formation of a bolus once it is modified by saliva are accomplished largely by the tongue. The tongue positions the bolus between the teeth and moves in a complex three-dimensional chewing pattern if the bolus requires mastication. The moistening of the food in the oral cavity is essential for normal bolus transit and/or flow and clearance, particularly because gravity provides no assistance until the vertical phases of swallowing.

The oral transport phase comprises movement of the cohesive bolus (masticated if necessary) posteriorly (and horizontally when the subject is in

a normal upright seated posture) to the inlet of the superior aspect of the vertical subsystem, the pharynx (Figure 31-4). The intrinsic tongue muscles change the shape and position of the tongue, forming grooves along its body and anterior and lateral seals to facilitate containment (Figure 31-4A), and then progressively arching the tongue posteriorly to transport the bolus to the vertical subsystem (Figures 31-4B and C).

FIGURE 31-4. Lateral view of bolus propulsion during swallowing. A. Voluntary initiation of the swallow by tongue “loading.” B. Bolus propulsion by tongue dorsum and upper esophageal sphincter (UES) opening anticipating bolus arrival. C. Bolus entry into pharynx associated with epiglottal downward tilt, hyolaryngeal excursion, and UES opening. D. Linguapharyngeal contact facilitating bolus passage through the pharynx. E. UES closing and completion of oropharyngeal swallowing; then the entire bolus is in the esophagus. (Adapted with permission from Robbins J. Normal swallowing and aging. Semin Neurol. 1996;16[4]:309–317.)

Ve rtical subsystem The pharyngeal and laryngeal components, in conjunction with the tongue dorsum, comprise the superior aspect of the vertical subsystem, where gravity begins to assist in the transport of the bolus. The anatomic juxtaposition of the entrance to the airway (laryngeal vestibule) and the pharyngeal aspect of the upper digestive tract demand biomechanical precision to ensure simultaneous airway protection and bolus transfer or propulsion through the pharynx. To this end, the pharyngeal transport phase is

characterized by a sequence of rapid, highly coordinated neuromuscular events that cause pressure changes critical to bolus transport or transit in a safe, timely, efficient manner.

Linguapalatal contact sequentially moves the bolus against the posterior pharyngeal wall, contributing to the positive pressures imparted to the bolus and propelling it downward. Simultaneously, the pharyngeal constrictors begin to contract in a descending sequence, first elevating and widening the entire pharynx to engulf the bolus (Figures 31-4D and E), and clean up residue after swallowing is completed. Tight closure of the velopharynx during the pharyngeal transport phase provides a seal at the superior aspect of the vertical system, preventing nasal leakage of the bolus and contributing to the generation of high positive pressures, which are applied to the bolus.

is accomplished. Three levels of sphincteric closure include (1) the aryepiglottic folds, (2) the false vocal folds, and (3) the true vocal folds, with closure of the true vocal folds (the lowest of the three sphincters) providing “the last line of defense” to prevent aspiration of invasive material. The hyolaryngeal complex is lifted upward and forward by the combined contraction of the suprahyoid muscles, thyrohyoid muscles, and pharyngeal elevators. This hyolaryngeal elevation and anterior movement, coupled with retraction of the tongue base, covers the laryngeal vestibule and diverts the bolus laterally around the airway. Timely relaxation and opening of the upper esophageal sphincter (UES) permits continuous vertical passage of the bolus into the esophagus. The UES functions as a mechanical valve.

For it to open normally, four criteria must be met: (1) relaxation of muscle tone, (2) compliant tissue, (3) traction force provided by sufficient hyolaryngeal excursion, and (4) pulsion force imparted by the bolus. In normal swallowing, UES relaxation and opening occur prior to bolus arrival at the hypopharynx.

Historically, swallowing was largely viewed as a sequence of pharyngeal and esophageal events and was defined as reflexive. However, it is now clear that normal swallowing is a patterned response rather than a traditional reflex.

Sensorimotor control of swallowing requires the coordinated activity to be distributed across both the cranial and spinal nerve systems, including the

peripheral nerves, their central nuclei, and their neural centers, as summarized in Table 31-2. This neural network spans all levels of the neuraxis from the cerebrum superiorly to the brain stem and spinal nerves inferiorly and muscles and end organs at the periphery. This relatively diffuse network is designed to integrate and sequence both the volitional and automatic actions of swallowing.

TABLE 31-2 ¦ NEUROMUSCULAR CONTROL OF SWALLOWING

Healthy persons depend on a highly automated neuromuscular sensorimotor process that intricately coordinates the activities of chewing, swallowing, and airway protection. To accomplish a normal swallow, which occurs in 2 seconds or less, the muscles of chewing interact with 26 pairs of striated pharyngeal and laryngeal muscles (see Table 31-2). Optimal structural integrity and precise neural mediation result in continuous, rapid bolus flow from the mouth to the esophagus (Figures 31-5A, B, and C) that accommodates variations in bolus size, texture, and temperature and the individual’s intent to swallow, chew, or just hold the bolus in the mouth.

FIGURE 31-5. Healthy young swallowing documented with videofluoroscopy. A. Bolus in oral cavity, ready to be swallowed. B. Bolus appears as a “column” of material swiftly moving through the pharynx. C. Oropharynx cleared of material when the swallow is completed. (Adapted with permission from Robbins J. Normal swallowing and aging. Semin Neurol.

Traditional thinking suggests that the causes of dysphagia are always disease- related, with direct or indirect damage to effector end-organ systems of swallowing. However, the swallowing changes with healthy aging, progressive changes of the anatomy, and physiology of the oropharyngeal swallowing mechanism put the older population at increased risk for dysphagia (Figure 31-6). Dysphagia occurs when an older healthy adult with diminished functional reserve is faced with increased stressors that elicit dysphagia only in a vulnerable individual. Such stressors include central nervous system (CNS)-altering medications, mechanical perturbations (eg, a nasogastric [NG] tube or a tracheostomy), or medical conditions (eg, frailty).

FIGURE 31-6. Model for interactions of aging effects leading to clinical outcomes of dysphagia. The onset of sarcopenia along with other factors leads to presbyphagia, or age- associated changes in swallowing, in healthy older adults. When older adults experience comorbid age-related disease or conditions, such as stroke or dementia, they are at increased risk for the development of dysphagia. Dysphagia is associated with a variety of negative health outcomes, including dehydration, malnutrition, and pneumonia, that increase the risk for hospital readmissions, morbidity, and even death.

The swallow of an older healthy adult is relatively slow. In people older than 65, the initiation of laryngeal and pharyngeal events, including laryngeal vestibule closure, maximal hyolaryngeal excursion, and upper UES opening, takes longer than in adults younger than 45. Although the specific neural underpinnings have not been confirmed, oral events may become uncoupled from the pharyngeal response. Thus, in older healthy adults, the bolus may remain adjacent to an open airway by pooling or pocketing in the pharyngeal recesses longer than in younger adults (Figure 31-7).

FIGURE 31-7. Healthy old swallowing documented with videofluoroscopy. A. Bolus in mouth ready for swallowing. B. Bolus pooled in vallecula and pyriform sinus during delayed onset of pharyngeal response. C. Bolus cleared of material when the swallow is completed. (Adapted with permission from Robbins J. Normal swallowing and aging. Semin Neurol. 1996;16[4]:309– 317.)

Aspiration and airway penetration are the most significant adverse clinical outcomes of misdirected bolus flow, as reflected in the high rates of pneumonia with increasing age and disease. While airway invasion is generally believed to be absent in healthy adults, under demanding conditions (eg, endurance = demanding), older individuals are less able to compensate and are more at risk for aspiration than younger people. Findings such as these differentiate presbyphagia from clinically abnormal swallowing.

Age-related changes in the generation of lingual pressure also define presbyphagia. Healthy older individuals have reduced isometric tongue pressures compared with younger individuals. In contrast, the generation of maximal lingual pressure during swallowing (which requires submaximal pressures) remains “young” in magnitude but slows in the time necessary to achieve those “young” swallowing pressures. The relationship between maximum isometric pressure and peak swallowing pressures can be considered an indication of the functional reserve available for swallowing. As people get older, slower swallowing may allow time to recruit the necessary number of motor units required for pressures critical for adequate bolus propulsion through the oropharynx. However, fluids of low viscosity (eg, water, tea), by their composition, are likely to move more quickly than the physiology to handle them safely and thus put older people at increased risk for aspiration.

The relationship between slower swallowing and increased number and severity of periventricular white-matter hyperintensities (PVHs) in the brain suggests that voluntary control of swallowing is mediated by corticobulbar pathways traveling within the periventricular white matter. These PVHs may explain, at least in part, the relatively asymptomatic decline in oropharyngeal motor performance observed in older people. Cerebral atrophy, a common finding in asymptomatic older individuals, may be another contributing factor to presbyphagia.

Changes in the periphery with age may be a function of changes in various sensory mechanisms or caused by muscle atrophy. Similar to the age- related loss of limb skeletal muscle, there are changes with age in muscle composition, muscle tension, muscle strength, and muscle contraction in facial, masticatory, and lingual musculature. Rather than reflecting CNS

deterioration, slowed swallowing that remains coordinated and effective, as found in most healthy old people, may represent a compensatory strategy for achieving pressure-generation values that may be critical to successful bolus propulsion.

Older adults are at increased risk for developing dysphagia because of a number of age-associated phenomena, comorbid conditions, and medications. By targeting high-risk groups and intervening with acceptable compensatory and rehabilitative approaches, it is hoped that the ultimate burden of dysphagia on the geriatric population will decline.

As illustrated in Figure 31-6, decreased physiologic reserve can combine with a number of age-related, disease-related, or iatrogenic changes to transform an at-risk individual into an older adult with dysphagia.

Sarcopenia, described in detail in Chapter 49, affects the head and neck musculature involved in swallowing. In fact, anterior and posterior isometric tongue pressure positively correlates with hand grip strength and with jump height and power. Furthermore, sarcopenia and worsening frailty status predict dysphagia prevalence in older adults.

Several anatomic or pathologic perturbations occurring throughout the orobuccal cavity, the laryngopharyngeal region, and the esophagus are also important cofactors in the onset of dysphagia. Additionally, age-related alterations in the neural coupling between respiration and swallowing result in more frequent occurrences of swallowing during the inspiratory phase in older adults. When the inspiratory phase is interrupted for swallowing rather than the expiratory phase, there is an increased risk for entry of material into the airway once inhalation is resumed.

Age-related conditions Age-related changes throughout the upper aerodigestive tract can influence swallowing integrity. Oral risks are also discussed in Chapter 32. During the oral phase, the food bolus may be inadequately prepared because of poor or absent dentition, periodontal disease, ill-fitting dentures, or inappropriate salivation caused by xerostomia. Salivary flow rate declines with advancing age and is exacerbated by xerostomia-inducing medications often prescribed to older adults. Certain organic components

within whole saliva, including secretory immunoglobulin A and mucoglycoproteins, also are reduced in older adults thereby altering the compositional makeup of saliva and affecting oral health. This decline in mucous properties can change the viscoelastic properties of saliva that may be important for bolus formation.

Musculoskeletal factors such as weakness of the muscles of mastication, arthritis of the temporomandibular joint or larynx, osteoporosis of the jaw, or changes in tongue strength and coordination of the oropharyngeal events can deter efficient swallowing. Sensory input for taste, temperature, and tactile sensation changes in many older adults. This disruption of sensory-cortical- motor feedback loops may interfere with proper bolus formation and timely response of the swallowing motoric sequence and detract from the pleasure of eating.

Material can penetrate into the upper airway in normal individuals if the bolus is not properly prepared, if the timing of the swallow is delayed, or if the intake is too rapid. Important risk factors for aspiration include altered level of attention during feeding (eg, delirium), altered sensory discrimination in the oropharynx, feeding problems, mechanical ventilation, and feeding tube placement. In the latter circumstance, the rate of tube feeding, the position of the patient, altered intestinal transit times, and the ability of the patient to protect their airway all influence the occurrence of reflux and aspiration and are discussed in detail in Chapter 30. There are subtle changes in lower esophageal sphincter (LES) function even in asymptomatic older individuals. Gastroesophageal reflux caused by LES incompetence as well as intraesophageal reflux (defined as material moving proximally within the esophagus prior to crossing the LES) also predispose individuals to micro- or macroaspiration.

Age-related disease Neurologic and neuromuscular disorders are principal risks for dysphagia (Table 31-3). Stroke, brain injury, Alzheimer disease, other dementia syndromes, and parkinsonism all place older adults at increased risk for dysphagia with its incipient consequences.

TABLE 31-3 ¦ NEUROLOGIC DISORDERS CAUSING DYSPHAGIA

Motor neuron di as (amyot?·ophic lateral scl r uillain-Barr' syr1drom and other poly??europathie

Because cognitive function and/or communication may be impaired, it is important for the practitioner to note the warning signs associated with dysphagia and risk of aspiration (Table 31-4). The entire eating process, which includes self-feeding (transferring food from the table to the mouth) in addition to swallowing, is affected in patients with dementia. The inability to eat safely is one of the most life-threatening impairments for these patients frequently leading to pneumonia onset. Between 50% and 75% of patients who have had a recent acute stroke develop eating and swallowing problems, with ensuing complications of malnutrition and pneumonia.

TABLE 31-4 ¦ WARNING SIGNS ASSOCIATED WITH DYSPHAGIA AND ASPIRATION RISK

A host of common problems involving the head and neck can directly damage the effector muscles of swallowing and increase the risk for dysphagia. Head and neck injury, carcinoma, complex infections, thyroid conditions, and diabetes are associated with age-related dysphagia. Although vertebral osteophytes are common, these bony growths alone rarely cause dysphagia. Dysphagia more commonly results from the presence of osteophytes in conjunction with neuromuscular weakness or discoordination. This can be caused by combinations of several underlying conditions or

comorbidities such as diabetes, chronic obstructive pulmonary disease, congestive heart failure, renal failure, an immunocompromised status, and/or cachexia for which an individual no longer can sustain adequate reserve to effectively compensate.

Sometimes dysphagia can be a direct consequence of a treatment provided for another disease process. Health care interventions can result in drug-induced delirium, protracted hospital stays, and ultimately malnutrition. Indwelling NG tubes, prolonged airway intubation resulting in laryngeal injury, and medication effects may all predispose a frail older adult with borderline airway protection to develop frank aspiration.

Older adults are much more likely to be taking medications for multiple medical conditions. These medications can influence salivary flow, intestinal peristalsis, cognition, or psychomotor status, thereby interfering with normal oropharyngoesophageal function or altering airway protection. More than 2000 drugs can cause xerostomia or reduced salivary flow via anticholinergic mechanisms. The list is extensive and can include common antidepressants, antihistamines, antipsychotics, and antihypertensive agents. Likewise, delirium-promoting drugs can produce adverse consequences through either anticholinergic or other central mind-altering effects. Certain agents can directly relax the LES and increase acid reflux and esophageal problems. Finally several psychotropic drugs can produce delayed neuromuscular responses or extrapyramidal effects, thereby influencing the tongue and bulbar musculature. Table 31-5 provides a partial list of these agents and how they can contribute to dysphagia.

TABLE 31-5 ¦ MECHANISMS BY WHICH COMMON MEDICATIONS CONTRIBUTE TO DYSPHAGIA

An altered level of attention and cognition may also produce special concerns with regard to safe eating and swallowing. Delirium is frequently underrecognized and undertreated in both hospital and institutional settings. In general, testing an inattentive adult for dysphagia results in the poorest evaluation. If swallowing is assessed during one of these episodes, aspiration is likely to occur. If a staff member at a hospital or nursing home feeds a patient during one of these intervals, the outcome may be disastrous.

Several different treatments can either directly or indirectly damage swallowing effector organs as described previously. Head and neck cancer surgeries, some spinal cord surgeries, thyroid surgeries, and any intervention that can jeopardize the recurrent laryngeal nerve may result in dysphagia. A number of chemotherapy and radiotherapy regimes can cause oropharyngeal injury. The prospective outcome of dysphagia should be incorporated into the risk-benefit discussions of these procedures.

Medical history plays a critical role in establishing a diagnosis of dysphagia (Table 31-6). A detailed history can elucidate the proper diagnosis in some dysphagic adults and is an important first step in the evaluation process.

Dysphagia may present in a more subtle fashion, without symptoms, but with recurring exacerbations of an underlying disease such as chronic obstructive pulmonary disease.

TABLE 31-6 ¦ HISTORICAL DATA USED FOR CLINICAL DIAGNOSIS OF DYSPHAGIA

Patients may initially complain of difficulty swallowing liquids, solid food, or pills. Caregivers or nursing personnel may note such difficulties experienced by the patient including “pocketing” of pills within the oral cavity. The patient may report more effort needed while eating. The patient or the patient’s observant family members may complain of the increased time needed to complete a meal. The patient or the practitioner may identify weight loss without any other localizing explanation. However, clinicians

must distinguish these dysphagia or aspiration symptoms from a myriad of other common health problems that may mimic dysphagia in older adults. For example, in frail individuals, depression or early Parkinsonism may be manifested solely by weight loss and slowed eating. Without a complete history, these patients may be sent for a dysphagia work-up before an attempt is made to manage their “root problem.”

Symptoms of esophageal dysphagia include food “hanging up” behind the sternum, neck pain, chest pain, and heartburn. A specific problem with solid food dysphagia suggests a mechanical obstruction. If the symptoms are intermittent, a lower esophageal ring may be present. If the symptoms are progressive, a peptic stricture or carcinoma is more likely. If there are difficulties in ingesting solids and liquids, a neuromuscular or dysmotility etiology must be considered.

Dysphagia evaluation varies depending on the clinical setting. The comprehensive diagnostic approaches available for hospitalized older patients with dysphagia may not be logistically feasible for bedbound nursing home residents. Likewise, interdisciplinary dysphagia teams are frequently available in academic settings or in larger hospital systems and less common in other settings. When such a team is not available, the responsibility for screening for swallowing problems falls on the primary provider or the hospital staff. Speech language pathologists, who are usually the swallowing therapists, are well trained to conduct bedside (also referred to as noninstrumental) examinations that include history taking, oral motor assessment, voice evaluation, and assessment of trial swallows. Prior to this referral though, clinicians can provide a focused secondary screening during their encounter with the patient. A number of attempts have been made to identify a simple screening tool for use in ambulatory clinics or at the patient’s bedside. A systematic review focused on dysphagia screening techniques for inpatients 65 years or older without stroke or Parkinson disease concluded that existing evidence is not sufficient to recommend the use of bedside tests in a general older population. While none of these approaches has proven altogether effective, certain approaches warrant mention (see Table 31-1 for an overview of selected available tools).

However, along with the risk of false negatives, bedside screening provides no information about the underlying pathophysiology of the swallow or for selecting specific interventions.

TABLE 31-1 ¦ SUMMARY DESCRIPTIONS OF SELECTED TOOLS FOR ASSESSING OUTCOMES RELATED TO EATING AND SWALLOWING

Despite these issues, owing to the high prevalence of swallowing difficulties in geriatric patients, some mechanism of primary screening needs to take place within a primary care clinic setting. Several validated

screening tools are listed in Table 31-1. Because swallowing is not something a patient usually mentions, it may be necessary to ask related questions until a particular word or phrase triggers an association with the patient’s experience (eg, swallowing, chewing, moving food to the throat, coughing, choking). Nonetheless, once dysphagia is suspected, a more complete assessment is necessary not only to validate its presence but also to define and construct a treatment plan that modifies the underlying sensorimotor pathophysiology.

An interdisciplinary team approach offers the stated advantage of a more efficient comprehensive assessment with shared responsibility for interventions and often makes timely consultation possible. The responsibilities of team members are often divided among disciplines and can include reviewing health issues, obtaining pertinent swallowing history, and an examination (which may include instrumental studies), providing education and counseling to the patient and to the family or the care provider, conducting psychosocial screening, and reviewing advance directives. Core teams frequently include a speech language pathologist, a dietitian, a social worker, and either a physician or a nurse practitioner.

A major function of the swallowing team is to perform a thorough assessment of the swallowing mechanism and its function. Most commonly, the speech language pathologist plays a major role, performing a two-part examination consisting first of a clinical (bedside) noninstrumental evaluation often followed by an instrumental assessment of swallowing.

The clinical evaluation is noninstrumental and although often referred to as a “bedside” procedure can be performed in a variety of environmental settings including an outpatient office. It usually involves four types of assessment:

(1) history taking; (2) speech and voice assessment; (3) oropharyngeal sensorimotor assessment; and (4) performance on trial swallows. The specific methods and measures preferred and most frequently used by clinicians when working with dysphagia of neurogenic origin, which is frequently the case in older patients, are shown in Table 31-7.

Although a noninstrumental assessment provides a breadth of information, it can only increase the suspicion of aspiration through findings such as increased secretions or a wet and/or gurgly voice quality. Given the possibility of silent aspiration as a result of decreased cognition or diminished sensation in older people, coughing and throat clearing, which are the characteristic signs of aspiration, may be absent. To rule out aspiration with an acceptable level of confidence, an instrumental assessment is often necessary. Moreover, effective dysphagia intervention relies on an accurate diagnosis of the specific pathophysiology. That is, the underlying movement disorder that results in disordered bolus flow in terms of direction, duration, and clearance, must be defined and remediated in order to eliminate or minimize the dysphagia. Most frequently, instrumental methods are necessary to clarify the aspects of the swallowing sequence that must be modified to effect safe and efficient bolus flow. Although clinicians must pursue a complete oropharyngeal and esophageal assessment of many dysphagic patients, this section focuses on oropharyngeal dysphagia, and the reader is referred to Chapter 85 for a discussion of esophageal disorder.

Oropharyngeal videofluoroscopic swallowing evaluation An oropharyngeal videofluoroscopic swallowing evaluation, or Modified Barium Swallow (MBS) study, is most commonly used to assess the integrity of the oropharyngeal anatomy, swallowing physiology, and bolus flow. Structural abnormalities and mucosal lesions are identified by the barium that is swallowed and used to outline the soft tissue structures it passes. Perhaps the two greatest strengths of the videofluoroscopic swallow evaluation are that the swallow is recorded in motion and preserved digitally or on videotape for replay. This method permits viewing of the dynamic swallow. All oropharyngeal structures can be examined with regard to their contribution to the coordinated (or uncoordinated) swallow in terms of timing and range of

motion. Their impact on bolus flow is made apparent. Therefore, the specific pathophysiology and its impact on bolus flow are clarified and can be targeted for treatment.

An oropharyngeal videofluoroscopic swallow study is not designed simply to determine if a patient is aspirating or even why a patient is aspirating or retaining residue. It is designed also to assist a clinician in determining if a patient can safely receive oral nourishment and allows for trials of proposed interventions to maximize efficacy and safety. During the study, the clinician often varies bolus characteristics sufficiently to be able to offer a diet recommendation (such as thickened liquid or semisolid).

Additional recommendations may be simple postural adjustments, such as tucking the chin, which are shown under fluoroscopy to improve direction or efficiency of bolus flow.

Although videofluoroscopy is the instrumental method most commonly used to assess swallowing, it is limited in the following ways:

(equivalent to 2 years of natural background radiation or a set of dental x- rays), videofluoroscopy is preferred for the breadth of information it provides with regard to anatomy, physiology, bolus flow, and assessment of trial intervention.

In addition, a fluoroscopic examination can easily be extended to the esophagus when indicated. Merging of the videofluoroscopic swallow study directly into esophagraphy, which results in a distinct third test referred to as an oropharyngeal esophagram, may reveal anatomic or physiologic findings for the referred sensation. Findings may include a Schatzki ring, an esophagus-narrowing web or stricture, a delay in LES opening or esophageal stasis, or other esophageal etiologies for the dysphagia. Thus, an oropharyngeal esophagram permits a more organized, efficient, cost-effective process for professional personnel and for the patient. Most importantly, it

optimizes the potential for comprehensive findings and facilitates immediate intervention.

Fiberoptic endoscopic evaluation of swallowing Fiberoptic endoscopic evaluation of swallowing (FEES) is second to videofluoroscopy in frequency of instrumental approaches used with older patients. It combines the traditional endoscopic examination, in which the flexible scope allows direct visualization of the nasal cavity, the entire nasopharynx, the oropharynx, the larynx, and the hypopharynx, with dynamic recording of swallowing.

Although FEES permits only limited observation of the pharyngeal swallow because it is “whited out” or visually obliterated during swallowing caused by constriction of the anatomy, the method provides a valuable alternative to a noninstrumental clinical assessment. It is being used with increased frequency in long-term care facilities where videofluoroscopy is unavailable and also with bariatric patients or those who cannot be moved to radiology because of medical instability. Other advantages are its repeatability, the use of real food and fluid during the assessment, and its potential as a biofeedback tool.

In addition to limited visualization of the dynamic oropharyngeal swallow, the limitations of FEES involve risks related to endoscopy, which include nosebleed, mucosal injury, gagging, allergic reaction to the topical anesthesia, laryngospasm, and vasovagal response. The unlikely possibility of encountering an adverse reaction during a flexible endoscope examination must be balanced against the daily risks faced by patients with dysphagia.

Adherence to dysphagia-related recommendations, whether thickened liquids or an exercise regimen, is known to be problematic. Reasons include not aligning therapy with the patient’s goals, poor insight into the extent of swallowing-related deficits, a lack of understanding regarding the importance of treatment for dysphagia, and inadequate patient education on the part of the clinician. A variety of patient-reported outcome measures, including the SWAL-QOL, Eating Assessment Tool (EAT-10), Sydney Swallow Questionnaire (SSQ), and the MD Anderson Dysphagia Inventory, allow clinicians to gauge the patient’s perspective of his or her swallowing impairment in order to tailor treatment to the needs of the patient, thereby supporting improved adherence.

Treatment for dysphagia is usually compensatory, rehabilitative, or a combination of the two approaches. Compensatory interventions avoid or reduce the effects of impaired structures or neuropathology and resultant disordered physiology and biomechanics on bolus flow. Rehabilitative interventions have the capacity to directly improve dysphagia at the biological level. That is, the targets of therapy are aspects of anatomic structures (eg, muscle) or neural circuitry that may have a direct influence on physiology, biomechanics, and bolus flow.

Traditionally, interventions for dysphagia in older patients are compensatory in nature and are directed at modifying bolus flow by targeting neuromuscularly induced pathobiomechanics or by adapting the environment.

Postural adjustme nts Postural adjustments are relatively simple to teach to a patient, require little effort to employ, and can eliminate misdirection of bolus flow through biomechanical adjustment. A general postural rule for facilitating safe swallowing is to eat in an upright posture so that the vertical phase of the oropharyngeal swallow capitalizes on gravitational forces at work. For patients with hemiparesis, a common strategy is a head turn toward the hemiparetic side, effectively closing off that side to bolus entry and facilitating bolus transit through the nonparetic pharyngeal channel. If the pathophysiologic condition is the uncoupling of the oral from the pharyngeal phase of the swallow, a simple chin tuck (45 degrees) reduces the speed of bolus passage, thereby giving the neural system time to initiate the pharyngeal and airway protection events prior to bolus entry.

Food and liquid rate and amounts Although we live in a “fast food” society, older individuals and especially those with dysphagia take longer to eat. Eating an adequate amount of food becomes a challenge not only because of the increased time required to do so but also because fatigue frequently becomes an issue. Typically, smaller amounts per swallow are less likely to enter or block the airway, but in individuals who experience a sensory loss in the mouth or throat, larger amounts of food or liquid may be necessary to trigger a swallow. To promote a safe, efficient swallow in most individuals with swallowing and chewing difficulties, the following recommendations are useful:

Adaptive equipment Eating and drinking aids can assist in placing, directing, and controlling the bolus of food or liquid and in maintaining proper head posture while eating. For example, modified cups with cutout rims (placed over the bridge of the nose) or straws prevent a backward head tilt when drinking to the bottom of a cup. A backward head tilt, which results in neck extension, should be avoided in most cases because when the head is tilted back, food and liquid are more likely to be misdirected into the airway. A speech pathologist or swallowing clinician can make suggestions regarding appropriate aids for optimizing swallowing safety and satisfaction.

Occupational therapists are experts in the area of adaptive equipment and can be helpful in obtaining products that are often available only commercially.

Diet modification The most common compensatory intervention is diet modification, a totally passive environmental adaptation. Withholding thin liquids such as water, tea, or coffee, which are most easily aspirated by older adults, and restricting liquid intake to thickened liquids is almost routine in nursing homes in an attempt to minimize or eliminate thin-liquid aspiration, presumably the precedent to the long-term related outcome, which is pneumonia. Despite the huge impact these seemingly unappealing practices may have on patient QOL, they have been commonly implemented in the absence of efficacy data.

Both chin-down posture and thickened liquids (nectar and honey viscosity) have been shown to be effective for patients with Parkinson disease and/or dementia. In the short term, aspiration is reduced with honey- thick liquids as compared with both nectar-thick and chin-down posture

interventions. Both chin-down posture and thickened liquids were equally effective in pneumonia prevention over 3 months.

Additional diet modifications include a pureed diet and a soft food diet in which the bolus maintains itself in a cohesive mass during transit but has more texture than the pureed diet. The use of sauces and gravies to minimize the formation of dry particles that may easily be misdirected into the airway is a common practice. Other strategies are also available, so the dietitian should work closely with the team to ensure that the safest diet is provided and that it is effective in maintaining adequate nutrition and hydration, while also acceptable to patients in order to enhance compliance.

Free water protocols Approaches have been developed to encourage intake of water to avoid dehydration in those patients with dysphagia who require thickened liquids. These “free water” protocols involve intensive oral care followed by ingestion of thin liquids between meals but thickened liquids during meals. While initial studies have shown no increased risk for lung complications in patients following these protocols, the findings are limited by small sample sizes and strict exclusion criteria that focus only on patients who are ambulatory, acute rehabilitation inpatients, and cognitively intact.

More research is needed to examine the safety and outcomes of these protocols in various older adult populations prior to clinical implementation.

Rehabilitative exercises are, by nature, more active and rigorous. Often a rehabilitative approach to dysphagia intervention is withheld from older patients because such a demanding activity is assumed to deplete any limited remaining swallowing reserve, thus potentially exacerbating dysphagia symptoms. Sufficient treatment efficacy data are unavailable, and so assumption-based patterns of practice prevail.

Given that progressive resistance training appears to be safe and effective for limb musculature in older adults, such training has been systematically applied to the muscles of swallowing. Several exercise regimens with efficacy data have been utilized with older adult populations including systematic tongue strengthening over 8 weeks, expiratory muscle strength training over 5 weeks, and a simple isotonic/isometric neck exercise (lying flat on back while lifting head with shoulders flat) over 6 weeks.

Additionally, preventative approaches that incorporate swallowing-related exercise regimens have begun to be implemented with older adults with the

goal of minimizing the effects of presbyphagia and increasing swallowing functional reserve.

Minimizing medications that may put a patient at risk for dysphagia is an important goal. Furthermore, pills are often described by patients as being difficult to swallow. Patients should be informed about medications that can be crushed, can be mixed with foods, or are available in liquid form. Pill- induced damage to the esophagus can occur if pills are taken when lying down or with inadequate amounts of liquid.

Poor oral hygiene is a risk factor for pneumonia, and aspiration of saliva, whether or not it is combined with food or fluid, can increase the likelihood of infection. The risk for periodontal disease as well as dental caries increases with age. Therefore, patients should be encouraged to perform oral hygiene several times a day and undergo periodic dental examinations.

Furthermore, products to relieve oral dryness in the form of saliva substitutes, as well as alcohol-free mouth care products, can be recommended.

Oropharyngeal dysphagia is potentially life threatening. In the older population, critical decisions often must be made that impact on the patient’s safety, health, and QOL. Among these perplexing issues is the question of continuing oral intake or providing nonoral enteral or parenteral nutrition.

Enteral nutrition, the delivery of nutritive products to the digestive system through nonoral means, is often selected for the temporary prevention of aspiration in acutely ill patients. It also is chosen for permanent replacement in patients whose disease process results in confirmed or suspected swallowing-related aspiration or malnutrition and dehydration. In the case of longer-term or permanent nutritive supplementation, the clinician’s impressions often direct decisions relating to tube feeding for weeks, months,

or even years in older patients whose chronic disease processes are overlaid on reduced functional reserve for safe, sufficient swallowing. However, it would clearly be narrow and short-sighted to make decisions with such an impact solely on the basis of empirical swallowing abilities or even instrumental physiologic and bolus flow test results. For an issue that may be a critical source of a patient’s sense of autonomy, self-respect, dignity, and QOL, swallowing ability is merely one factor in a decision-making formula. It is also important to consider that feeding tubes are associated with their own risks and poor long-term outcomes. NG tubes can result in agitation, nasal irritation, and sinus infection while gastrostomy tubes may lead to cellulitis, fasciitis, and bacteremia. Both types of feeding tubes increase the risk of diarrhea as well as pressure ulcers with slower healing of existing sores. There is currently no evidence to support that feeding tubes prolong survival in patients with dementia and dysphagia or that early placement improves recovery of function or length of stay in patients with post-stroke dysphagia. In fact, the Ethics and Clinical Practice Committees of the American Geriatrics Society published a comprehensive review of the evidence about feeding tubes and dementia in 2014 and issued position statements that suggest placement of feeding tubes in patients with dementia should be seriously reconsidered. Other approaches, such as hand feeding, are preferred for this population.

In summary, while oropharyngeal dysphagia may be life threatening, so are the alternatives, particularly for frail older patients. Therefore, contributions by all team members are valuable in this challenging decision- making process. The patient’s family or care provider’s point of view is also critical but second, of course, to that of the competent patient, himself. The state of the evidence calls for more research, including randomized controlled trials (RCTs) in this area. Until then, the many behavioral, dietary, and environmental modifications described in this chapter and being further refined are compassionate and, in many cases, preferred alternatives to the always present option of tube feeding.

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Cabre M, Serra-Prat M, Force L, Almirall J, Palomera E, Clave P. Oropharyngeal dysphagia is a risk factor for readmission for pneumonia in the very elderly persons: observational prospective study. J Gerontol A Biol Sci Med Sci. 2014;69(3):330–337.

Gillman A, Winkler R, Taylor NF. Implementing the Free Water Protocol does not result in aspiration pneumonia in carefully selected patients with dysphagia: a systematic review. Dysphagia. 2017;32(3):345–361.

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Malandraki GA, Perlman AL, Karampinos DC, et al. Reduced somatosensory activations in swallowing with age. Hum Brain Mapp. 2011;32(5):730–743.

Martin-Harris B, Brodsky MB, Michel Y, et al. MBS measurement tool for swallowing impairment- MBSImp: establishing a standard. Dysphagia. 2008;23(4):392–405.

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in patients with oropharyngeal dysphagia: white paper by the European Society for Swallowing Disorders (ESSD). Dysphagia.

Nicosia MA, Hind JA, Roecker EB, et al. Age effects on the temporal evolution of isometric and swallowing pressure. J Gerontol A Biol Sci Med Sci. 2000;55(11):M634–640.

Robbins J, Coyle J, Rosenbek J, et al. Differentiation of normal and abnormal airway protection during swallowing using a penetration- aspiration scale. Dysphagia. 1999;14(4):228–232.

Robbins J, Gensler G, Hind J, et al. Comparison of 2 interventions of liquid aspiration on pneumonia incidence: a randomized trial. Ann Intern Med. 2008;148:509–518.

Rogus-Pulia NM, Rusche N, Hind J, et al. Effects of device-facilitated (D-F) isometric progressive resistance oropharyngeal (I-PRO) therapy on swallowing and health-related outcomes in older adults with dysphagia. J Am Geriatr Soc. 2016;64(2):417–424.

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The centrality of the mouth to human health, function, and behavior is clear. The abilities to eat, smile, speak, and interact with others are essential functions. This chapter presents the contributions of the mouth to health and function in an older person’s life. The components of the oral cavity are described along with age-related and disease-related changes, how to evaluate geriatric patients’ oral conditions, and when to refer. The impacts of oral conditions on quality of life are described, as are disparities in access to and outcomes of oral health care and the importance of prevention in health status. Finally, goals of long-term oral health care are described, along with options for long-term oral health care.

Specialized tissues have evolved in the orofacial region that allow us to speak, process food, and protect us from pathogens and trauma (Table 32-1). The teeth, the periodontium, and the muscles of mastication prepare food for swallowing. The tongue plays a central role in communication and is a key participant in food bolus preparation and translocation. Salivary glands provide secretions with multiple functions; saliva lubricates oral mucosal tissues keeping them intact and pliable, and moistens the food bolus into a swallow-acceptable form. These activities are finely coordinated; a disturbance in any one function can compromise speech, alimentation, and the quality of a patient’s life (Table 32-2).

TABLE 32-1 ¦ ORAL TISSUES AND THEIR FUNCTIONS

TABLE 32-2 ¦ ORAL-PHARYNGEAL PROCESSES IN OLDER ADULTS

The oral cavity is exposed to the external world and is vulnerable to infectious, traumatic, and environmental insults. Mechanisms have evolved to

protect the mouth and permit normal oral function. Local infections that can affect the oral cavity are summarized in Table 32-3.

TABLE 32-3 ¦ CLINICAL MANIFESTATIONS OF ORAL INFECTIONS

The oral cavity is richly endowed with sensory systems that contribute to the enjoyment of food and alert an individual to potential problems. These systems include taste (and its inextricable relationship with smell); thermal, textural, and tactile sensation; and pain discrimination. Saliva plays an important protective role and contains a broad spectrum of antiviral, antibacterial, and antifungal proteins that modulate oral microbial colonization. Biomarkers of systemic (eg, C-reactive protein [CRP], interleukin [IL]-6) and oral inflammation are present in saliva. Other proteins maintain the functional integrity of teeth by keeping saliva supersaturated

with respect to calcium and phosphate salts and provide the first role in repairing early dental caries (tooth decay) via a remineralization process.

Key Clinical Points

Oral health screening should be part of the patient’s initial history and physical examination.
A preventive model of oral health care for all older adult patients includes fluoride-containing gels, varnishes, rinses and pastes, antibacterial rinses, electric toothbrushes, floss threaders, and other adaptive methods.
Many common medications have adverse effects on the oral cavity and oral health.
Disease in the oral cavity can diminish a patient’s overall health and quality of life.
Common systemic medical conditions may affect oral health and vice versa, and may affect dental treatment.

The loss of teeth has long been associated with aging. However, older adults lose teeth not because of age per se, but because of dental diseases. National surveys in the United States (NHES, NHANES) demonstrate that each successive age cohort has less tooth loss than the prior one. Thus, the percent of 65- to 74-year-olds who had lost all their teeth decreased from 55% in 1958 to 1959 to 29% in 1988 to 1994, to 24% in 1999 to 2004, and 13% in

Tooth loss has two major causes: dental caries (discussed later) and periodontal diseases (discussed in the next section). Dental caries mostly affect exposed tooth surfaces, and periodontal diseases affect the supporting bony and ligamentous dental structures. With the current trends toward increasing tooth retention in aging populations, there is a correspondingly greater risk for the development of both of these disease entities.

A tooth consists of several mineralized and nonmineralized components supported by the periodontal ligament and the alveolar bone (Figure 32-1). The outer dental structure (enamel) is the hardest mineralized component, approximately 95% hydroxyapatite. Enamel covers the coronal portion of the tooth and is the first hard tissue exposed to caries-causing bacteria. Dentin, approximately 72% mineralized, constitutes the main portion of the tooth structure, extending almost the entire length of a tooth. It is covered by enamel on the crown and by cementum on the root. Cementum is the least mineralized of the three components (~ 50%) and is the component most susceptible to caries-causing bacteria. The central, nonmineralized portion is the dental pulp, which houses the vascular, lymphatic, and neuronal supply to the tooth. Stem cells are present in pulpal tissues.

There are two classifications of dental caries, depending on the tooth surface affected. Coronal caries occurs when the enamel and dentin of the crown portion of the tooth (usually above the gums) are affected. In older adults, if gingival (gum) recession or periodontal disease causes the root surfaces of the tooth to become exposed to the oral environment, root surface caries may occur.

The primary caries-causing microorganisms are Streptococcus mutans; oral streptococci, Actinomyces, and lactobacilli are also associated with coronal and root surface lesions. These bacteria reside on the tooth surface in dental plaque, a soft, firmly adherent mass that contains bacteria, food debris, desquamated cells, and bacterial products. Acid production by plaque bacteria dissolves the mineral content of the enamel, dentin, or

cementum. The exposed proteins are destroyed by hydrolytic enzymes, resulting in early dental caries. Dental plaque is considered a primary etiologic factor in dental caries, as well as a principal source of pathogenic organisms in periodontal diseases.

As older adults live longer and maintain their permanent dentition, there is susceptibility to coronal caries due to recurrent decay bordering existing fillings and the increased prevalence of root surface caries. There are many risk indicators for root surface caries: increased age, decreased exposure to fluoride, coronal caries, periodontal attachment loss, diminished oral-motor skills required for oral hygiene, and additional medical, behavioral, and social factors.

For an older adult with teeth, dental caries is a significant concern and may be a source of pain, infection, and difficulty chewing or swallowing, resulting in a compromised diet or malnutrition. Dental caries will appear as orange to dark brown lesions that frequently are associated with dental plaque (Figure 32-2A and B). Long-standing dental caries ultimately result in the destruction of the tooth with the possibility of local or disseminated infection in the maxillofacial tissues, space infections in the head and neck, and infection in the systemic circulation (septicemia). Once teeth have been destroyed from dental caries or periodontal disease, mastication, phonation, and swallowing are perturbed. Finally, social contact and nutritional status may be affected in an edentulous aging individual.

FIGURE 32-2. A. Dental caries, dental plaque, and B. gingival recession in two patients with dementia.

The prevention of dental caries in an older adult includes use of fluoride in many forms, daily effective oral hygiene, and regular visits to dental professionals. Tooth surfaces can become resistant to decalcification and decay through repeated exposure to fluoride in water supplies, toothpaste, rinses, high-strength prescription gels, and varnishes. However, even

resistant tooth surfaces can decay when oral hygiene is poor and the mouth is dry and/or exposed repeatedly to fermentable carbohydrates. When detected early, dental caries can be debrided from a tooth, and the missing tooth structure can be restored with a wear-resistant, insoluble restorative material (eg, amalgam or composite resin). Some restorative materials contain fluoride (glass ionomers) and can help reduce caries risk. Replacements for lost teeth are available with complete or partial dentures, crowns, bridges, or implants.

The periodontium consists of the tissues that invest and support the teeth. It is divided into the gingival unit (gums) and the attachment apparatus (cementum, periodontal ligament, and alveolar bony process) (see Figure

32-1). Gingivitis occurs when the gingival unit alone is inflamed. Periodontitis (periodontal disease) exists when there is inflammation, infection, and an appreciable loss of the attachment apparatus as a result of the presence of pathogenic microorganisms. Microbial species (eg,

Porphyromonas gingivalis, Bacteroides, Fusobacterium, Prevotella, Actinobacillus, Actinomyces, Capnocytophaga, and others) cross through the gingival epithelium and enter subepithelial tissues, where they activate

host defense mechanisms. Eventually, this causes tissue destruction, including bone loss, mobility, pain on eating, and tooth loss.

Periodontal diseases are more prevalent in the aging population than with younger adults. Sixty-four percent of persons in the United States age 65 and older have moderate or severe periodontal diseases. Older persons experience greater gingival recession and loss of periodontal attachment (see Figure 32-3). Periodontal disease proceeds through a series of episodic attacks rather than occurring as a slowly progressing continuous process.

Bone destruction results from an overly aggressive local immune reaction to the pathogenic organisms, triggering a cascade of cytokine and immunologic events that can produce irreversible loss of alveolar bone. Among healthy adults, periodontal attachment loss occurs at small increments in all age cohorts and does not occur in greater amounts in older healthy adults.

However, many systemic diseases and therapeutic regimens commonly found in older individuals adversely affect periodontal health. Therefore, older, medically compromised adults and smokers are especially susceptible to

developing periodontal diseases and at risk for associated dental-alveolar infections, pain, and tooth loss.

Medication-induced changes: Several classes of medications commonly prescribed for older people are associated with gingival enlargement and hyperplasia, a condition that if left untreated, predisposes people to both dental caries and destructive periodontitis. Some calcium channel blockers (eg, nifedipine), phenytoin, and cyclosporine can cause this unwanted drug side effect, which may require periodontal surgery.

Periodontal-systemic connections: Periodontal diseases have oral and systemic effects on health. They are directly associated with halitosis, gingival bleeding, tooth mobility, and tooth loss. Untreated periodontitis has been reported to interfere with blood glucose control in patients with diabetes; and cardiovascular disease is associated with periodontitis after controlling for traditional risk factors such as body mass index (BMI), gender, tobacco use, age, and blood lipid levels. Gram-negative bacteria are implicated in the pathogenesis of periodontal disease, and colonization of the oropharynx with gram-negative bacilli predisposes a patient to pneumonia.

aspirated into the lungs, causing infection. Bacteria from the gingival sulcus in persons with periodontitis have been isolated from patients with pneumonia. Risk factors for aspiration pneumonia include older age, immunocompromised state, mechanical ventilation, feeding problems and/or feeding tubes, deteriorating health status, and wearing dentures during sleep. Importantly, debilitated older patients who do not have adequate oral hygiene care are highly susceptible to aspiration pneumonia.

Treatment of gingivitis and periodontitis starts with good oral hygiene in the form of tooth brushing for 2 minutes twice daily and flossing daily.

Electric toothbrushes can assist older patients who have arthritis, motor, and/or cognitive disorders. Periodontal therapy ranges from local (dental prophylaxis, local debridement, scaling, and root planing) to pharmacologic (intrasulcular antimicrobial solutions, systemic low-dose doxycycline as an immunomodulator) to surgical techniques (debridement, excision of hyperplastic tissue), depending on the extent of periodontal infection and bony destruction. Several antimicrobial and anticollagenase drugs have been approved for treatment: oral rinses (chlorhexidine 0.12%), subgingival antimicrobials (minocycline hydrochloride 1-mg microspheres), short-term antimicrobials (clindamycin 300 mg QID or metronidazole 400 mg TID for 7–10 days), or anticollagenases (doxycycline 20 mg). While periodontal healing after surgery tends to be slower even in healthy older persons, the long-term results of periodontal therapy are indistinguishable from those in younger adults. The decision either to save the dentition and restore periodontal health or to extract teeth with moderate periodontal disease should be determined after all oral and systemic factors have been evaluated. The health and functional status of a person, rather than age per se, should determine the extent of periodontal treatment.

There are three major pairs of salivary glands (parotid, submandibular, and sublingual) and numerous minor glands (labial, palatal, and buccal); their principal function is the exocrine production of saliva. Each gland type makes a unique secretion derived from either mucous or serous cell types, forming the fluid in the mouth termed whole saliva. Saliva includes many constituents that are critical to the maintenance of oral health. Saliva

lubricates the oral mucosa, promotes remineralization of teeth, and protects against microbial infections. Saliva helps prepare the food bolus for deglutition, dissolves foods, and delivers tastants to the taste buds.

Nevertheless, there is a common clinical observation that older individuals have xerostomia (dry mouth) and voice concern of said condition. Further, there appear to be no significant alterations in the composition of saliva in older, healthy persons.

The physiologic findings contrast with the morphologic changes seen in aging salivary glands. Major salivary glands lose approximately 30% of their parenchymal tissue over the adult life span. The loss primarily involves acinar or fluid-producing components, while proportional increases are seen in ductal cells and in fat, vascular and connective tissues. Because acinar components are primarily responsible for the secretion of saliva, it is not known why, in the presence of a significant reduction in the gland acinar volume, total fluid production does not diminish with increasing age. Current thinking is that salivary glands possess a functional reserve capacity that enables them to maintain fluid output throughout the human adult life span.

There is evidence that with a reduced reserve capacity, additional burdens placed on aging salivary glands (eg, anticholinergic medications) increase vulnerability to functional decline. Therefore, salivary hypofunction (the objective finding) and complaints of xerostomia (the subjective finding) should not be considered normal sequelae of aging but instead are indicative of a variety of diseases and their treatments (Table 32-4). Many medications taken by older adults reduce or alter salivary gland performance, as can dehydration. In addition, radiation for head and neck neoplasms and cytotoxic chemotherapy have direct and dramatic deleterious effects on salivary glands.

TABLE 32-4 ¦ CAUSES OF SALIVARY HYPOFUNCTION IN OLDER ADULTS

The most common disease affecting salivary glands is Sjögren syndrome, an autoimmune exocrinopathy that occurs predominantly in postmenopausal women. Alzheimer disease, diabetes, dehydration, rheumatoid arthritis, and cerebrovascular accidents may also affect salivary output. Several oral inflammatory and obstructive salivary gland disorders (eg, bacterial infections, sialoliths, trauma, neoplasms) result in salivary dysfunction, as well as benign and malignant salivary tumors.

A clinician is likely to encounter many older patients with oral complaints related to salivary gland hypofunction. Clinical examination

includes palpation of all major glands and inspection of the duct orifices while milking the glands to ensure gland patency. The application of a mild solution of citric acid or lemon juice to the tongue can help determine whether a patient’s salivary glands will respond to a gustatory stimulus.

Regardless of etiology, any of the major oral physiologic roles influenced by saliva (see Table 32-1) may be affected adversely. With impaired glandular output, dental caries will increase, increasing the possibility of tooth loss.

The oral mucosa becomes desiccated and cracked, leaving the host more susceptible to microbial infection (Figure 32-4). Older adults with salivary gland hypofunction may experience difficulty swallowing or speaking at length, pain (which may arise from either the teeth or the oral soft tissues), impaired denture use, altered taste, and diminished food enjoyment.

Treatment of salivary dysfunction starts with identification of the etiology. Medication-induced salivary problems can be eliminated by stopping unnecessary medicines, modifying drug use and dose, or substituting one drug with another drug that has fewer anticholinergic side effects. Even when no reduction in the daily dose is recommended, the splitting of a dose into several smaller and more frequently taken doses may alleviate or

diminish the sensation of oral dryness. To enhance salivary production, gustatory (sugar-free mints, candies), masticatory (sugar-free gums), and pharmacologic (pilocarpine 5 mg TID and qhs, cevimeline 30 mg TID) stimulants can be useful in a patient who has remaining salivary function. Salivary substitutes, rinses, and moisturizing gels can assist a patient who has little or no remaining salivary function. Prevention of xerostomia is essential and can be achieved with the frequent use of noncarbonated, caffeine- and sugar-free beverages, topical fluoride, and routine oral hygiene no less than twice daily. Full (complete) and partial removable prostheses (dentures) must be kept clean and out of the mouth during sleeping hours.

Frequent lubrication of the lips will help prevent lip cracking, trauma, and infections.

When food enjoyment, recognition, and sensory function decline in an older person, significant nutritional deficits can result. The question of whether there is a true anorexia (loss of appetite) associated with aging is confounded by many comorbidities, common in older people, that may cause anorexia, and social and psychological factors that may reduce oral food and fluid intake. Perturbations in taste, smell, and other oral sensory modalities can occur with age and with dental/periodontal problems, thereby reducing the rewards of eating and contributing to a diminished interest in food by some older persons.

The taste receptors of the human gustatory system are distributed throughout the oropharynx and are innervated by three cranial nerves: VII, IX, and X. The number of lingual taste buds does not diminish with age. The registration of a taste phenomenon is complex, because multiple factors are involved: gustation, olfaction, and central nervous system function. The ability to taste is often evaluated at two levels: (1) threshold, the most common measure, a “molecular-level” event, which reflects the lowest concentrations of a tastant that an individual can recognize as being different from water, and (2) suprathreshold, a measure that is reflective of the ability to taste the intensity of substances at functional concentrations encountered in daily life. In addition to detection, recognition, and intensity, the normal sensation of taste involves a hedonic component: the degree of pleasantness.

Taste function among healthy, community-dwelling individuals changes modestly with increased age. In contrast, a threefold increase in the

frequency of subjective taste complaints has been observed among older persons who take prescription medications. Objective threshold and suprathreshold evaluations of gustatory function in healthy older adults have been reported for all four taste qualities (sweet, sour, salty, and bitter). In general, the changes detected with increased age are modest and taste- quality-specific. For example, the ability of older adults to detect salt decreases slightly with age, while no changes in the detection threshold for sucrose (sweet) are noted. The importance of medication usage and place of residence in the evaluation of taste dysfunction has been confirmed in clinical studies in which institutionalized persons and those using more prescription medications had elevated taste thresholds.

Older adults perform less well in the more complicated problems of flavor perception, food recognition, and food preference. This is probably a result of diminished olfactory performance rather than the modest changes that accompany taste function with aging. Olfactory performance data show declines in thresholds, suprathreshold intensity judgments, and odor recognition in both men and women with increasing age. Among older adults, average thresholds are higher, the ability to perceive suprathreshold intensities is blunted, odor recognition is impaired, and the judgment of pleasantness is reduced compared with younger subjects. Moreover, longitudinal studies demonstrate that as people get older, recognition decrements become even more severe.

Normal chemosensory function does not operate independently of good oral health. Numerous oral conditions can directly or indirectly affect smell and taste by altering the underlying biology of the taste or smell system or by introducing exogenous stimuli into the mouth or nose. Fungal/bacterial/viral infections, vesiculobullous diseases, salivary gland hypofunction, poorly fitting prostheses, and oral manifestations of systemic diseases can cause chemosensory dysfunction. Inadequate removal of food particles allows their breakdown or by oral microorganisms to noxious, unpleasant substances.

Periodontal diseases can result in accumulations of putrefied materials that may leak into the oral cavity and alter taste sensation. Similarly, dental- alveolar bacterial infections with subsequent fistula formation may contribute continuously low levels of purulent matter in the mouth.

The complaint of a smell or taste problem may be indicative of a chemosensory disorder or could be the manifestation of an oral and/or systemic medical problem. For example, the sudden loss of either smell or

taste may be a sign of brain tumor or COVID-19. Alternatively, gradual diminishment in food enjoyment may be related to multiple sources.

Examples include a poorly fitting removable prosthesis (Figure 32-5), an oral fungal infection (see Figure 32-4), decreased smell identification, or use of a new drug. A patient should be asked if he or she can specifically identify the four basic tastants and distinguish between different odorants; such patients could be given the University of Pennsylvania Smell Identification Test. A thorough multidisciplinary approach is required for a patient presenting with chemosensory complaints because of the wide range of potential oral, systemic, physiologic, cognitive, and pathologic factors that are involved in oral sensory functioning.

FIGURE 32-5. Denture scar on palate in patient with xerostomia (dry mouth). Arrow highlights the denture scar on palate.

Three general types of soft tissue line the mouth: (1) well-keratinized tissue with a dense layer of connective tissue and firmly attached to underlying bone (marginal gingiva, palatal mucosa), (2) slightly keratinized and freely movable tissue (labial and buccal mucosa, floor of the mouth), and (3) specialized mucosa (dorsum of the tongue). The primary function of the oral

mucosa is to act as a barrier to protect the underlying structures from desiccation, noxious chemicals, trauma, thermal stress, and infection. The oral mucosa plays a key role in the defense of the oral cavity.

Aging can be associated with changes in the oral mucosa similar to those in the skin, with the epithelium becoming thinner, less hydrated, and more susceptible to injury. The reasons for these changes are complex and include alterations in protein synthesis and responsiveness to growth factors and other regulatory mediators. Cell renewal (ie, mitotic rates) and the synthesis of proteins associated with oral mucosal keratinization occur at a slower rate in aging individuals. Normal tissue architecture and patterns of histodifferentiation, which probably are dependent on complex interactions with the underlying connective tissue, do not display any changes with age.

Overall, changes in the vascularity of oral mucosa likely contribute to alterations in mucosal integrity because of reductions in cellular access to nutrients and oxygenation. Mucosal, alveolar, and gingival arteries can be affected by arteriosclerosis. Varicosities on the floor of the mouth and the lateral and ventral surfaces of the tongue (comparable to varicosities in the lower extremities) are also observable in some geriatric patients.

The maintenance of mucosal integrity depends on the ability of the oral epithelium to respond to insults caused by physical factors (trauma), exposure to chemical or microbiological toxins, microbial infections, and oral and/or systemic conditions. Although the immune system generally declines with age (see Chapter 3), it is unknown whether this decline extends to mucosal immunity. If so, the oral mucosa and gingival tissues may be more susceptible to transmission of infectious diseases as well as delayed wound healing.

Although age has no effect on the clinical appearance of the oral mucosa, the use of removable prostheses has a potentially adverse effect on the health of the oral mucosa. The denture-bearing mucosa of aged maxillary and mandibular ridges shows morphologic changes. Ill-fitting dentures can produce mechanical trauma to the oral tissues (see Figure 32-5) and cause mucosal hyperplasia. Oral candidiasis can frequently be found on denture- bearing areas in an edentulous individual, often occurring with angular cheilitis (deep fissuring and ulceration of the epithelium at the commissures of the mouth). The clinician should ask the patient to remove all removable dentures before conducting an oral screening.

Oral mucosal alterations in an older person are often a result of multiple oral and systemic factors (Table 32-5). Many medications have been associated with oral mucosal changes, and long-term use of antibiotics frequently results in oral candidal infections, while drugs with xerostomic side effects (see earlier) increase the potential for mucosal injury.

Bisphosphonate drugs used for cancer metastasis and osteoporosis (especially those administered intravenously) are associated with increased risk for osteonecrosis, a severe destruction of oral mucosa and bone.

However, risk for the rare event of osteonecrosis must be balanced against the benefit of bisphosphonate drugs for common osteoporosis-related fractures. Drugs used in older patients for arthritic conditions, hypertension, cardiac arrhythmias, seizures, and dementia are associated with lichenoid- like reactions. The withdrawal of a causative drug usually results in complete resolution of the lesion within 2 to 3 weeks, but if there is no clinical improvement, a definitive diagnosis should be obtained with a biopsy specimen.

TABLE 32-5 ¦ CONDITIONS ASSOCIATED WITH ORAL MUCOSAL CHANGES

Many oral mucosal disorders can affect older people, ranging from benign (eg, recurrent aphthous ulcers and traumatic lesions) to malignant (eg, squamous cell carcinomas) (Figure 32-6A and B). The diagnosis of mucosal diseases requires a detailed history and a thorough head and neck and oral examination, including all mucosal tissues. For vesiculobullous and erosive diseases, a simple three-item classification is helpful: (1) acute multiple lesions (eg, erythema multiforme, herpes simplex, herpes zoster, allergic reaction), (2) recurring oral ulcers (eg, recurrent aphthous stomatitis, traumatic ulcer), and (3) chronic multiple lesions (eg, pemphigus vulgaris, mucous membrane pemphigoid, lupus erythematosus, lichen planus,

dysplasia, squamous cell carcinoma). If a lesion does not resolve after 2 to 3 weeks, a tissue biopsy is required. For lesions that are suspected to be oral manifestations of autoimmune connective tissue disorders (eg, pemphigus, pemphigoid, lichen planus), biopsies should also include specimens for direct immunofluorescence. If trauma from an injury or an ill-fitting denture is suspected, removal of the etiology should allow the lesion to heal. Many of these conditions have an immunologic etiology, and therefore management strategies involve topical and/or systemic immunomodulating agents (Table 32-6).

TABLE 32-6 ¦ TREATMENT OF COMMON VESICULOBULLOUS AND EROSIVE DISEASES IN OLDER ADULTS

Topical treatments,:;.-d Fluoci,nonide gel.0.05% T1·iamcinol,o,ne aceto?i:de 1n gel base 0.1%

bOral can?tidia is ???a}' resu.lt, and oonc:o.n?imnt a??ti u?l tl?er.?py may be neces.sary;

"Car?.b com,b??(?d J??,a J:1 ???ixtt[re:,,,rirh st·?cral&t?e, Ka?pectate, r M?. lox..

. os.e a??d dt?ration dcpend.o? ·c,•erity f di?.a e a.??d concQ?nitai?t 5)<Ste 1ic <ii??s.e.s.

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FIGURE 32-6. A. Squamous cell carcinoma, floor of the mouth. B. Squamous cell carcinoma, soft palate, retromolar pad.

The oral mucosal disease with the greatest potential morbidity and mortality is cancer (see Figure 32-6A and B). Oral cancers represent 2.9% of all cancers. There were an estimated 53,260 new oral and pharyngeal cancers in

the United States in 2020 and 10,750 cancer deaths. The 5-year survival rate is 66%. Median age at diagnosis is 63; 80% of new cancers occur after age 55; and median age at death is 68. Five-year survival for localized cancers (29% of oral and pharyngeal cancers) is 85%, for cancers that spread to regional nodes (48%) is 67%, and for metastatic oral and pharyngeal cancers (19%) is 40%. The greatest risk factors for developing oral cancer are age, tobacco, heavy alcohol use, and human papillomavirus (HPV). Males are more than twice as likely to develop oral cancer as females.

Carcinoma should be considered part of the differential diagnosis of any oral lesion. Any oral lesion that does not heal completely in 2 to 3 weeks after removal of suspected etiologies (eg, ill-fitting denture, change in medication) should undergo a diagnostic biopsy procedure.

The treatment of oral cancers involves head and neck surgery, radiotherapy, chemotherapy, or a combination of any of these three modalities, depending on the tumor’s histopathology and stage. Before receiving definitive therapy, the patient should have a comprehensive oral examination so that focal areas of infection or potential infection (dental caries, periodontal disease, dental-alveolar infections, soft and hard tissues lesions) can be treated before surgery, radiotherapy, or chemotherapy. The patient must be educated about many potential risks: surgery-related sensory, esthetic, and functional problems; radiotherapy-induced mucositis, salivary gland hypofunction, and osteoradionecrosis; and chemotherapy-induced mucositis and immunosuppression.

The oral motor apparatus is involved in routine yet intricate functions (speech, posture, mastication, and swallowing). Regulation of these activities may occur at three levels: the local neuromuscular unit, central neuronal pathways, and systemic influences. While aging is associated with changes in neuromuscular systems, animal studies suggest that age-associated deficiencies in motor function are unrelated to the composition and contractile function of skeletal muscles. Rather, these changes probably are related to other factors such as neuromuscular transmission and propagation of nerve impulses.

While older adults with an intact dentition prepare food more slowly for swallowing than do younger individuals, and minor alterations in

performance (mastication, swallowing, oral muscular posture, and tone) can be expected with increased age, changes are more common among completely or partially edentulous persons rather than among persons with a natural dentition. Any diminution in masticatory efficiency can be exacerbated in individuals with a compromised dentition (persons with dental caries, periodontitis, missing teeth, and removable dentures).

Swallowing changes in older persons are usually caused by sensory, muscular, and neurologic deterioration. A thorough review of swallowing problems in older people is provided in Chapter 31, Disorders of Swallowing. Normal aging has minor adverse effects on swallowing, although in a healthy older person, even advanced age does not appear to cause any clinically important dysfunction. However, a host of conditions common in the older adult population can cause clinically significant swallowing deficiencies. Salivary hypofunction (described earlier) impairs swallowing times and under severe conditions increases the likelihood of aspiration. Patients with neuropathies have been reported to have oral swallow times four- to sixfold longer than those in healthy controls; these persons may not even be able to produce the recognizable characteristics of an oral swallow. Neurovascular conditions (eg, cerebrovascular accidents, dementia, motor neuron disease) and Parkinson disease are likely to cause dysphagia and predispose a person to the danger of aspiration.

The temporomandibular joint (TMJ) is located between the glenoid fossa and the condylar process of the mandible, and exhibits a functionally unique gliding and hinge movement. It is of particular interest to clinicians, for it is the focus of several craniofacial pain disorders. Radiographic and postmortem evaluations suggest that the components of this joint undergo degenerative alterations with increasing age. However, TMJ functional impairment is not a “normal” age-associated event. Rather, temporomandibular disorders (TMD) in older adults are linked with many common oral and systemic conditions. Orofacial pain in an older patient may be a result of a variety of problems of the craniomandibular complex and other extraoral diseases, making diagnosis and treatment challenging and frequently requiring a multidisciplinary approach.

In general, two types of pathology are associated with the TMJ: articular, related to the joint itself, and nonarticular, pathology occurring in structures unrelated to the joint but causing similar or referred symptomatology. Articular abnormalities common to all joints may also

affect the TMJ: for example, trauma, ankylosis, dislocation, and arthritis. Nonarticular disorders may result from trigeminal neuralgia, headache, migraine, otitis, dentoalveolar pain/infection, and masticatory myalgia.

Orofacial habits (eg, jaw clenching and tooth grinding) and poor head and neck posture can produce muscle fatigue and spasm. Psychological conditions (stress and depression) can exacerbate underlying articular and nonarticular disorders. Clinically, the patient will present with pain in many regions: TMJ, temporal, neck, masticatory muscles, and the oral cavity.

Diagnosis is challenging because symptoms primarily occur in any of these sites with regular, irregular, or no pain referred to the TMJ region. Limited jaw opening (< 40 mm from the maxillary central incisor to the mandibular central incisor edges) and pain on mastication or during jaw movements may be indicative of TMD. Treatment, as with other arthritic or muscular disorders, requires an appropriate diagnosis and ranges from conservative and reversible regimens (anti-inflammatories, analgesics, muscle relaxants, physical therapy, oral bite splints) to more invasive procedures for unresolved painful conditions (eg, TMJ surgery). Pain in the jaws and/or face is present in 3% to 6% of persons age 65 and older.

Speech is another function of the oral structures; speech undergoes changes with increasing age, including shape of the tongue and its function during sound production and frequency variability. Among healthy older persons, these changes do not compromise or alter speech in any perceptible way. Tongue strength decreases with age, even among healthy adults, yet tongue endurance is similar between younger and older persons. There are also age-associated alterations in intraoral and maxillofacial posture.

Drooping of the lower face and lips in the older adult results from the loss of supporting hard tissues and diminished tone of the circumoral muscles. The latter changes may elicit esthetic concerns and can lead to embarrassment from drooling or food spills caused by the inability of an older individual to close the lips competently while eating or speaking. Often, drooling caused by reduced circumoral muscle tone can result in complaints of excess salivation. Finally, oral motor disorders also may result from therapeutic drug regimens, such as the frequent association of tardive dyskinesia with phenothiazine therapy. These dyskinesias may include diminished performance and speech pathologies as well as alteration in movement (eg, chorea).

Poor oral health diminishes the quality of life among persons with poor general health. There is a strong association between poor general health and poor oral health (Figure 32-7A and B). Persons who report poor general health are more likely to have complete tooth loss compared to older people reporting good or better general health. Older adults with teeth reporting poor general health also have two to four fewer teeth than persons reporting good or better general health. Further, the mean number of teeth in persons 50 years and older reporting poor general health is below the threshold for a functional dentition (20 teeth are considered the minimum for a functional dentition). Persons reporting poor general health are also more likely to report painful aching in their mouth. Conditions that increase the likelihood of reporting pain include arthritis, chronic obstructive pulmonary disease (COPD), cardiovascular disease (CVD), diabetes, and low/no vision. One in five adults between age 65 and 74 who report poor general health also report avoiding particular foods because of poor oral health (problems with their teeth, dentures, or mouth).

FIGURE 32-7. A. Tooth loss and caries are more prevalent in older adults with fair/poor health. B. Oral quality of life by self-reported health. The Y axis in both A and B is percent prevalence. (Data from Griffin SO, Jones JA, Brunson D, et al. Burden of oral disease among older adults and implications for public health priorities. Am J Public Health. 2012;102[3]:411- 418.)

Nearly 73 million baby boomers will turn 65 by 2030. Most will lose dental insurance upon retirement. Medicare does not cover dental care except in very narrowly prescribed circumstances. Medicaid coverage varies by state; in 2011, 22 states provided “comprehensive,” 7 provided limited, 14 provided emergency, and 7 provided no dental coverage for adults.

However, Medicaid is only for people at or below the poverty level. Thus, a large “middle” group of older people are on a fixed income with limited access to sponsored dental care coverage. Such people need private dental coverage and/or effective, community-based prevention programs.

There are important disparities in access to dental care, tooth loss, unfilled caries, periodontal diseases, and oral cancers among the poor, near poor, and racial and ethnic minorities. Insurance affects access for persons age 65 and older : “54% of adults with private health care coverage had visited dental professional within the past 6 months, compared with 41% of adults who had only Medicare and 25% who had Medicare plus Medicaid” (CDC, 2014). Thus, the so-called dual eligibles are the most likely group of older persons to not have access to dental care. In addition, while past dental care use has improved slightly among persons age 65 and older since 1999 to 2004 for persons above 200% of the federal poverty level (FPL), it is lower among persons below 200% of this level (Figure 32-8A).

FIGURE 32-8. A. Percent with past year dental care use among 65+ year olds, USA, 1999- 2004 and 2011-2016. B. Percent with untreated dental caries among 65+ year olds, USA, 1999- 2004 and 2011-2016. C. Percent with edentulism and untreated dental caries among 65+ year olds by income, race and ethnicity, USA, 2011. Federal poverty level (FPL) is a measure of income issued every year by the Department of Health and Human Services (HHS). (A & B, Data from Griffin SO, Thornton-Evans G, Wei L, et al. Disparities in dental use and untreated caries prevalence by income. JDR Clin Trans Res. 2021;6[2]:234–241. C, Data from Griffin

SO, Griffin PM, Li CH, et al. Changes in older adults’ oral health and disparities: 1999 to 2004 and 2011 to 2016. J Am Geriatr Soc. 2019;67[6]:1152–1157.)

Baby boomers will be keeping their teeth longer and in greater numbers than ever before; however, dental decay (caries) is now as much of a problem in older adults as in children. NHANES caries data from 1999 to 2004 and 2011–2016 (Figure 32-8B) showed that among persons age 65 and older, prevalence of unfilled caries was higher among persons below 200% of the FPL (18% vs 25%) in contrast with persons 200% or more of the FPL, where unfilled caries rates were lower in 2011 to 2016 (16% vs 14%).

NHANES data from 2011 to 2016 show that unfilled decay was highest among Mexican Americans, non-Hispanic Blacks and the poor, while complete tooth loss (edentulism) is lowest among Whites and highest among the poor and African-Americans (Figure 32-8C). Disparities in access and dental conditions are the starkest in nursing homes and senior centers. In nine Basic Screening Surveys across the United States, edentulism ranged from 25% to 43% (median 33%) and unfilled caries from 25% to 53% (median 40%). National SEER data show that new oral and pharyngeal cancer rates are highest among male Whites, yet death rates are highest among African- American men (Figure 32-9).

FIGURE 32-9. Oral and pharyngeal cancer incidence and deaths by race and ethnicity, sex, per 100,000, USA, 2013-2018. (Data from SEER:

The initial examination and radiographic series by an oral health professional can yield the greatest diagnostic value. This information will not only serve as a diagnostic tool for the immediate treatment needs but also as a baseline that can be used to map the progression of disease or a decline in the patient’s oral health. For frail medically compromised (homebound or institutionalized) older adults, subsequent visits can be more challenging when there has been an overall decline in the patient’s medical and physical condition or psychological state.

For nondental health professionals on the interdisciplinary geriatrics team, it is important to take a couple of minutes to complete an intraoral evaluation. Any clinical findings that differ from the routine normal color and structure are indications for referral to a dental health professional. Along with the clinical intraoral evaluation, it can be very helpful for the nondental health professional to ask two simple questions:

“Do you have any pain or discomfort in your mouth?” “Do you have any trouble biting or chewing your food?”

A positive response to one or both predicts the need for treatment. Any combination of positive responses to these questions should also trigger a referral for consultation to an oral health care provider with formal training or experience with special needs adults or geriatric dental medicine. Often the most important step is the early identification of the clinical problem, and referral to the appropriate provider. Lack of an early referral may result in a missed opportunity to aid the patient with their oral health needs. The interdisciplinary team working together can ensure that the needs of the patient are addressed in a timely and thorough manner. Important interactions may involve the primary care physician, specialist physician, nurse, nurse practitioner, physician assistant, dentist, dental specialist, dental hygienist, dental assistant, and health aides. One key goal is to determine the need for antibiotic premedication prior to dental treatment. Premedication is often considered for patients with risk for endocarditis, autoimmune disease, chemotherapy, joint replacement, or heart murmurs. Another goal is to establish appropriate antianxiety premedication regimes for patients with

psychiatric, social, and medical conditions to ensure that optimal dental treatment can be rendered efficiently.

When performing an intraoral assessment, the clinician should use a strong light source and take the time to systematically review all anatomic landmarks in the oral cavity. An instrument such as a dental mirror or tongue blade plus use of fingers with a dry gauze can be used to isolate and retract tissues within the oral cavity to properly access and evaluate each structure. For example, it is impossible to evaluate the floor of the mouth without physically retracting the tongue and gaining direct vision. At a minimum, an oral health screening should include the hard palate, soft palate, uvula, tongue, cheek, lips, floor of the mouth, gingiva/gums, and teeth. It is important to document and report any findings in a referral for dental treatment. This report should include any mobile, decayed, missing, or fractured teeth along with any structure that is loose or does not follow normal size, color, or texture. Any sign or symptom of an abscess or infection in the oral cavity should be reported immediately. If a physician starts the patient on a course of antibiotic for a dental infection, that should also be noted to avoid repetition of the antibiotic.

By the time of transition to a nursing home for long-term care, many frail older adults already need dental care. There is a clear need for community- based prevention before older people require long-term care. Prior to embarking on programs to prevent caries and other oral diseases in older people using, for example, fluoride varnish, patient navigation, and patient- centered counseling, it is important to take a community-based participatory approach to find out what older people want, and what would be acceptable options for preventive care.

As the end of life draws near either in the long-term care setting or at home, goals of dental care may shift from aggressive treatment to a focus on comfort, safety, dignity, and preservation of function. In a Delphi study of the goals of oral health in long-term care, the 10 most important goals are shown in Table 32-7.

TABLE 32-7 ¦ TOP 10 ORAL HEALTH OUTCOMES IN LONG- TERM CARE

The overall goal in these special populations is to be proactive as opposed to waiting for problems to arise. Prevention and early detection are paramount to avoid more complex problems that may require a more invasive treatment plan for the patient. In many cases, this increases the financial burden for the patient, the family, or the facility.

First, it is important to identify any limitations the patient may have. Oral health care should ideally be practiced in the morning when the patient wakes up, after each meal, and at their hour of sleep. In some cases, patients are not able to gain access to care at each of these points in a day due to the lack of available assistance. When assistance is available, the oral hygiene should be practiced as often as possible, but no less than twice daily.

When obstacles are introduced, such as a patient with arthritis who is unable to hold the small handle of a toothbrush, the plan needs to be modified so it is doable. The solution to this example could be as simple as creating a larger handle by wrapping a sponge around the brush and securing it with medical tape, placing two small slits in a tennis or racquet ball and sliding the brush into the slits, securing the brush in a bicycle handle or purchasing an electric toothbrush with a larger handle. In most cases, the action of the

electric brush can take the place of the movements that once were accomplished by the patient.

It is also important for patients to continue to see the oral health team on a regular basis. The number of visits needed for older adults could range from quarterly to semiannual or an annual evaluation for the edentulous patient. These routine visits along with a strong care plan for twice-daily oral hygiene will greatly decrease the risk of complex problems arising in the oral cavity. The patient’s physician should communicate any major health changes to the oral health team, who will be able to assist in finding solutions for new barriers. When delivering oral health care within a long- term facility it is important to consider the cooperation and participation of the staff, patients, their families, and the administration. Without the support of the administration, delivery of oral health care is difficult. There are many models that can be designed to best fit the needs of each specific population. At a minimum, the facility should provide the space and time required to properly treat each patient and allow staff access for in-service training as required by the facility.

The late Dr. Jonathan Ship wrote this chapter in the 6th edition. While we are not able to include him as an author in this chapter, much of the material from that chapter has been retained in this edition. The authors are grateful for Dr. Ship’s enduring leadership and lifetime contributions to the field of geriatric dental medicine and oral health in the older adult population.

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Many large, population-based, cross-sectional studies have documented the increase in prevalence of eye disease and visual impairment with increasing age, particularly in people older than 75 years. Greater prevalence of vision loss in the population with advancing age is a common feature across available data reports, despite a fair degree of variability in estimates and projections as a function of data type, source, definitions, and approach. Year 2020 prevalence estimates for vision loss in the United States, for instance, are 4.8% (16 million) of the population and 10% of those age 50 and older (12 million; International Agency for Prevention of Blindness Vision Atlas, https://www.iapb.org/learn/vision-atlas). The Centers for Disease Control and Prevention (CDC) and the National Centers for Health Statistics (NCHS) estimate the prevalence of significant visual impairment among Americans age 18 to 44 is 5.5%; the prevalence in those age 45 to 74 is approximately 12% and is rising to more than 15% for those age 75 and older. Indeed, according to a 2016 National Academies of Sciences, Engineering, and Medicine Report, of all adults with vision impairment or blindness who were 40 years and older in 2015, nearly half (48% or 2 million) were at least age 80. Projections for the year 2050 indicate the proportion of US adults age 80 and older will expand to account for 63% (5.6 million) of adults age 40 and older with vision impairment or blindness. After age 85,

one in four older people are vision-impaired—unable to read, drive, recognize faces, and perform everyday activities without assistive devices and rehabilitation training. The prevalence of all forms of vision loss are projected to increase. Higher numbers of visually impaired older adults are non-Hispanic White women.

Age-related visual impairment is not only challenging to the person who develops it, but also affects society as a whole. The total economic burden of eye disorders and vision loss in the United States has been estimated at $139 billion for the year 2013. More than half of these costs ($77 billion) were incurred by Americans age 65 and older, with $30 billion direct medical expenditures for eye disorders and low vision care, vision aids, adaptations, devices and assistance.

Medicare beneficiaries with coded diagnoses of vision loss incurred yearly eye-related costs ranging from $237 to $407 per patient depending on severity of loss. Beneficiaries with vision loss were also shown to incur an additional $2.1 billion in non–eye-related medical costs. Additional non– eye-related costs per patient yearly were $2193, $3301, and $4443, respectively. Health utility (distress, pain, depression, lack of mobility, social limitations) was converted into quality-adjusted life years, and the total lost value for this factor was $11 billion. Significantly higher overall health care utilization and expenditures among patients with vision loss relative to patients without vision loss is a persistent issue consistent with comparatively higher prevalence of chronic comorbidities in this population. Vision loss may in fact amplify mortality and morbidity risk associated with this greater chronic comorbidity burden.

Patients with vision loss experience a number of health care access barriers. Gaining physical access to providers and other health professionals and health facilities as well as difficulties with patient–provider communication and limited availability of accessible health education and information to support adherence to recommendations and self-care following health care visits and stays elucidate some of the ways in which vision loss can limit effective patient-centered care. Having vision impairment was associated with lower patient satisfaction with care ratings among Medicare beneficiaries in 2017.

Recent analytic population health reports describing specific health care utilization disparities among older adults with vision loss affirm prior reports regarding the economic impact of eye disorders and vision loss in the United States. Older adults with vision loss were less likely to complete recommended preventive health screenings, had longer average length of hospital stay, higher readmission rates, and higher incurred hospitalization and post-discharge costs relative to comparisons without vision loss. While

more remains to be understood, it is clear that prevention of vision loss in the first place, or early detection and timely referral for low vision assessment and rehabilitation are key to minimizing the significant health, disability, and economic burdens exacted by vision loss in aging.

Vision loss is reason enough for a decline in function among older people, but vision loss has also been associated with declines in cognition, hearing, mobility, well-being, and overall quality of life. Older visually impaired people are twice as likely to have difficulty walking as do sighted peers, three times more likely to have difficulty getting outside, more than twice as likely to have difficulty getting in and out of a bed/chair, and three times more likely to have difficulty preparing a meal.

The most prevalent age-related causes of visual impairment in the United States are macular degeneration, diabetic retinopathy, glaucoma, and cataract. Approximately 60% of people with visual impairments who are not institutionalized have one or more additional impairments. These include the loss of hearing, impaired mobility and greater falls risk, decreased energy and stamina from respiratory and heart disease, and cognitive changes resulting from stroke or dementia. Vision loss has been ranked third, behind arthritis and heart disease, among the most common chronic conditions causing older people to require assistance with activities of daily living (ADLs). Because the majority of people with visual impairments have useful vision, rehabilitation services and vision-enhancing techniques and devices offer opportunities to increase their visual and general functional capacity.

Every older person experiences age-related changes in vision. The majority of these age-related changes are not amenable to correction with spectacles. Table 33-1 summarizes the age-related changes that cause functional declines for older people. Decreased transmission of the ocular media, increased scatter in the cornea, lens, vitreous body, and retina as well as decreased pupil size are related to anatomic changes in the aging eye. The age-related changes discussed here are those that have the greatest impact on function in daily life. The importance of accommodating these typical, age-related changes in visual function cannot be overstated. Age-related changes in

vision affect nearly all older adults and manifest in the absence of eye pathology. Their impacts on aspects of health self-management and cognitive function, for instance, are only beginning to be appreciated. Age-related changes in vision must be taken in account when considering the daily living, quality of life, and the design of facilities for all older people.

TABLE 33-1 ¦ NORMAL AGE-RELATED CHANGES IN VISION

Accommodation The ability to accommodate for focus on visual targets from distance to near, which is dependent on a flexible crystalline lens and the ciliary muscle, is altered with age, beginning around age 45. During this change, an increasing amount of plus in a concave lens (usually prescribed in bifocal lenses or reading glasses) is required to boost the focusing power of the eye to compensate for the loss in refracting ability of the lens for near tasks.

Visual acuity The visual acuity of nonvisually impaired older people shows only a modest decrease under high-contrast conditions, but reducing the illumination of an acuity chart, reducing the contrast of the acuity chart, and/or adding surrounding glare, produces drastic age-related acuity losses, as compared to young observers. For example, in a sample of 900 older observers, for those at age 82, the median high-contrast visual acuity was 20/30, low-contrast high-luminance acuity was 20/55, low-contrast low- luminance acuity was 20/120, and low-contrast acuity in glare conditions was 20/160. The added challenge of less than optimal lighting and/or contrast between the letters and their background means that older adults have difficulty resolving detailed visual information at the same distance as younger observers. The combined challenge of low contrast stimuli and less than optimal illumination significantly reduces visual acuity relative to young comparisons. A young observer loses only about one line of acuity under similar conditions. Thus, older adults’ visual acuity is dramatically reduced under less than optimal viewing conditions. Older people need higher contrast and two to three times more light to see than a younger person. Low contrast and low lighting adversely impact the visual function of older people, and modification of visual materials and environmental lighting are helpful.

Adaptation to changing lighting conditions Because of anatomic changes in the eye and media, older people require more light to support adequate vision; however, they are also more sensitive to glare, such as very bright direct light or reflected bright light in the environment. As a result, older adults are more likely to experience momentary glare disability and take longer to recover from glare exposure (eg, camera flash, bright headlights) relative to younger persons. The adverse effects of glare may have the most impact on activities such as walking outdoors or driving, but may affect indoor activities as well. Because adaptation to changing levels of light is slowed in aging, the momentary vision loss and visual discomfort experienced when moving between dim and very bright environments (eg, from a dim restaurant, or theater, into a sunny day) may limit how well important targets that must be viewed for the sake of safety are seen. Glare sensitivity has been associated with motor vehicle accidents for older drivers.

Attentional visual field Attentional visual field, the visual field area over which one can detect and process rapidly presented visual information, declines with age. Unlike conventional measures of visual field that assess visual

sensory sensitivity (such as static flashing lights), attentional visual field relies on higher-order processing skills such as selective and divided attention and rapid processing speed. Decreased attentional visual field has been correlated to a greater incidence of driving accidents and is related to a greater risk for balance and mobility problems for nonvisually impaired older people. Attentional visual field can be improved with training, but such training is not widely available.

Reading rate Visual reading ability decreases with age as well. The reading rate of older people who do not have a vision loss and have good high- contrast visual acuity still decreases by as much as a third of that of young readers. Accuracy of reading, however, can remain comparable to that of younger readers. Reading performance among older people with good acuity (20/30) is highly correlated with attentional visual field; those with good reading performance into very old age also retain good attentional fields as well. Low-contrast visual acuity is also correlated with reading performance for this population; older people with poor low-contrast acuity tend to read more slowly. Even when high-contrast acuity is good, older people, especially the oldest old, are at risk for reading difficulties that may arise from a combination of reduced attentional visual field, reduced accuracy and efficiency of eye movements, and poor low-contrast visual acuity. Reading ability can be supported by optimizing lighting, contrast and typography (font size and type, spacing, leading, kerning, line length) of text materials.

Moreover, reading rate for nonvisually impaired older adults with good high- contrast acuity and good comprehension skills can be improved with training. Training in reading efficiency that emphasizes improvements in eye movements for reading similar to those exercises used to improve reading for school children has given good results for this population. Such training, however, is not widely available.

Color discrimination Color discrimination is another aspect of vision that declines with advancing age. People who are older have greater difficulty detecting differences between very dark colors (eg, brown, black, or navy). Particularly challenging are tasks that involve green-blue-violet color discriminations, or distinguishing between very light, pastel colors (eg, light yellow, peach, light green, light blue—common medication pill colors). Loss of color vision in old age is related to smaller pupil diameter (miosis), reduced light transmission through the lens which yellows and thickens with age, and changes in photoreceptors and neural pathways.

Dark adaptation Dark adaptation ability and speed decline as a result of losses in ocular transmittance and pupillary miosis resulting from the aging process. Difficulty with slowed dark adaptation can be limiting to older adults moving from light to dim environments and vice versa. The risk for stumbling or falling may be greater under these circumstances (eg, exiting a theater into a bright, sunny day). During the protracted adaptation period the nonvisually impaired older person may function as if severely visually impaired when required to transition quickly between environments with drastically different levels of illumination.

Spectacles and falls risk Although not related to a change in vision per se, care must be taken in providing refractive correction in spectacle form for geriatric patients. Multifocal spectacle lenses either in the form of bifocals or varifocals are commonly prescribed but are associated with a higher risk of “edge of step” accidents, and multifocal lens wearers are twice as likely to fall as single-focus lens wearers. A large percentage of these falls are reported to occur outside the home, perhaps as a result of tripping or stumbling resulting from obstacles not seen in the near-vision correction of the lower visual field. The bifocal portion of a spectacle correction provides additional dioptric power to provide vision at near distance for reading, etc. This means that objects outside this near-focal range, such as steps, curbs, stairs, pets, etc., are blurred and indistinct. This effect is greatest in older patients, as the need for extra dioptric power for near vision increases with age. Patients with multifocal correction are encouraged to tuck their chins and look over the top of the bifocal correction when moving so that they can look through the distance correction in the upper portion of the lenses, but head flexion significantly increases postural instability. Encouraging those who are at risk for falling to explore these issues with their eye care specialists, who may recommend separate “near” and “distance” spectacles or other solutions, can be an important aspect of falls prevention.

The changes in healthy aging vision described above are common and experienced by nearly all people as they grow older. This does not minimize the importance of using, and recommending, the strategies described above to minimize the impacts of age-related changes in visual function on daily life.

The impacts of the aging visual system described are evident in the absence of eye conditions or disease and amplify functional impairments if pathology does develop. The most prevalent age-related causes of visual impairment are described next.

Age-related macular degeneration Functional vision loss due to age-related macular degeneration may include metamorphopsia (visual images appear distorted and wavy), relative scotomas, as well as dense central scotomas for those whose pathology progresses to visual impairment. Individuals with central scotomas in both eyes usually develop a strongly preferred retinal locus or loci (PRL) that performs as the primary fixation reference, although the patient may not always be aware that there is a scotoma present. The loss of central visual field results in loss of visual acuity and contrast sensitivity. The ability to use the PRL that develops for fixation may be difficult for many people. The effects of macular degeneration on daily life include difficulty with reading print, inability to recognize faces (that can lead to reluctance to participate in social activities), difficulty with distance and depth cues (that adversely affect safe mobility), and loss of color and contrast sensitivity (that interferes with a variety of household and work/leisure tasks) (Table 33-2).

TABLE 33-2 ¦ AGE-RELATED CAUSES OF VISUAL IMPAIRMENT

Diabe tic re tinopathy The progression of diabetic retinopathy includes macular edema that may cause blurred vision if the fovea is involved, retinal hemorrhages (and/or laser treatments), which may result in scattered central, peripheral, and/or midperipheral scotomas, and retinal detachment, which can cause larger areas of field loss if not reattached. Diabetic retinopathy can progress to total blindness. Loss of function can include decreased visual acuity, scattered field loss over the retina, metamorphopsia across the retina, increased sensitivity to glare, and loss of color and contrast sensitivity. If the fovea is lost to scotoma, then a PRL or multiple PRLs will likely develop.

Vision fluctuations can be manifested over time as macular swelling increases or subsides, and can also be related to hemorrhage. Sudden vision loss is common following hemorrhage, with the patient describing episodes of smoky vision, a dropped veil over the eye(s), or seeing black or red strings across the field of view. Treatment and absorption of blood can improve acuity, though not usually to normal levels. The effects on daily life include difficulty reading print materials, difficulty recognizing faces, increased sensitivity to glare and light/dark adaptation, difficulty with

distance and depth cues, loss of color and contrast sensitivity, and fluctuating vision.

Cataract Age-related cataract is manifested by gradual opacity of the lens, which interferes with the passage of light, causing reduced visual acuity, light scatter, sensitivity to glare, altered color perception, and image distortion (straight lines appear wavy). People with cataracts may experience trouble with glare and loss of contrast, may have decreased acuity, and report areas of metamorphopsia or small scotomas in the visual field. When the cataract has begun to interfere with lifestyle, surgery may be performed to remove either the entire lens or the posterior portion. Correction for the removal of the lens is provided primarily through intraocular lens implants, but occasionally eyeglasses or contact lens are used instead. Cataract surgery is the most common major surgical procedure done for people older than age 65 who are receiving Medicare funding. Cataract surgery with lens implantation is associated with improved objective and subjective measures of function in ADLs, as well as improved levels of vision to normal acuity in most cases.

Glaucoma Glaucoma is an increase in intraocular pressure caused by an abnormality in flow of aqueous fluid from the anterior chamber. It can cause a degeneration of the optic disk, loss of visual fields, and severe visual impairment. When left untreated, or if treatment is not successful, glaucoma results in a loss of peripheral fields and can lead to blindness. The effect of peripheral field loss on daily life is most problematic in safe ambulation.

Because of field restrictions, the patients may not see objects in their path and may bump into objects that fall outside the field of view in any direction (street signs, tree branches, other people, etc). In addition, a person outside the patient’s field of view may suddenly be seen as a “jack-in-the-box” and create a startle effect. Peripheral field loss may also create problems in reading and writing as only a small portion of the page can be seen at once.

Traumatic brain injury and stroke Head injury to older adults from falls or automobile accidents resulting in traumatic brain injury (TBI), as well as brain injury due to strokes, can lead to visual impairment. Between 20% and 40% of strokes result in visual disorder that can inhibit cognitive functioning and may reduce the effectiveness of rehabilitation of the TBI. Visual field disorders can result from injury to the visual pathway anyway between the retina and the striate cortex. The optic chiasm is an anatomic landmark that

differentiates the peripheral (prechiasmatic) and the central (postchiasmatic) visual pathway. Unilateral injury to the prechiasmatic pathway affects the ipsilesional field only, but postchiasmatic injury causes visual deficits in both monocular hemifields that are referred to as homonymous. Visual field disorders must be discerned by visual field measurement techniques called perimetry. Patients are often unaware of field loss and may not report the lost visual field/s, but they may suffer from their effects, for example, bumping into objects, tripping, falling, being unable to read, etc. Vision can be completely lost in the missing field, or some vision function (eg, light detection) may remain. The most common visual field losses are hemianopsia (loss of half the visual field), followed by quadranopsia (loss of one quadrant) and paracentral scotoma (island of vision loss in the parafoveal region). Recovery of some visual field following injury may be spontaneous, and some patients learn spontaneously to adapt to visual field loss by oculomotor strategies; shifting gaze may reveal what is missing in the field of view of a street scene (such as an oncoming car) or the missing portion of a line of text. Systematic training in oculomotor adaptation and visual perceptual training can improve vision function and has the ability to improve the perceived visual field. Visual field loss may also be accompanied by visual neglect. Older adults with neglect may not spontaneously be able to attend to the neglected side. TBI may also result in disorders of visual space perception, which affect reach (over- or underreaching for objects, knocking objects over), driving (accidents resulting from inability to judge distance and depth), and reading (inability to plan and execute accurate eye movements). Visuospatial localization and orientation may be improved through training, but may not reach pre-TBI thresholds. Visual agnosia, a failure to visually recognize an object because of “mistaken identity,” is a disorder that is based in both visual-perceptual and visual-cognitive functions. Typically, misidentifications result from the incomplete or inappropriate use of object features such as size, shape, or color. Older adults with TBI may be unaware that they are ignoring other features that might assist with correct identification. Cognitive and/or communication disorders can make visual impairment more difficult to detect following TBI. Undetected or untreated visual impairment in TBI can limit the effectiveness of other TBI rehabilitation. For example, many cognitive and functional assessments use visual items that cannot be appropriately identified by older people with vision loss; visual motor assessments require

eye-hand coordination. If TBI vision loss is not detected and treated to the extent possible, the examiner or therapist may get a false-negative impression of the level of TBI disability. In addition, the TBI patient will be frustrated and troubled unduly by participating in rehabilitation that does not simultaneously address the vision deficit. Integrated, interdisciplinary team- based care is key.

After diagnosis and medical management of the patient’s vision loss, the geriatrician can play an important role in assuring that visually impaired people receive rehabilitation services that are of high quality, are sought in a timely manner, and provide all the benefit that the patients might be able to derive from them.

A geriatrician can provide the following services for their patients related to vision rehabilitation:

Patients likely to benefit from vision rehabilitation include those with reduced acuity of less than 20/50 in the better-seeing eye, central or peripheral field loss with intact visual acuity, reduced contrast sensitivity, glare sensitivity, and/or light/dark adaptation difficulties as well as those with TBI. Candidates for cataract surgery with macular disease might also benefit from preoperative low-vision assessment and coincident rehabilitation training that enhances postoperative visual performance and satisfaction with a cataract procedure.

The clinical and functional low-vision examinations for older people should distinguish aging from treatable disease processes; focus holistically; incorporate family and caregiver support; identify what matters most to the patient; and set realistic patient-centered goals as part of interdisciplinary team-based plans of care to improve functional status and quality of life.

In health care service delivery to older adults with low vision, certain aspects of the examination sequence are adapted to accommodate these principles.

Because most age-related visual impairments result in a central scotoma, most patient complaints will be related to the loss of acuity, loss of central visual field, and resultant decrease in contrast sensitivity and color sensitivity. Patient goals for rehabilitation will usually include reading, writing, independence in ADLs such as meal preparation and household maintenance, management of glare and other illumination concerns, leisure activities, and safe independent movement and travel. Older people may also have specific health-related activities that require the use of vision (eg, loading a syringe with insulin, changing an ostomy bag); these will be goals as well.

This information may be taken by a pre-examination telephone interview to lessen the amount of time the first examination visit might require. Because low-vision rehabilitation requires a great deal of energy and motivation from the patient, it will be guided by their personal goals for rehabilitation and by those tasks that are difficult or impossible to perform because of low vision. In this regard, the intake interviewer may find that some education is necessary in order to set reasonable goals for low-vision treatment. Because most low-vision interventions and assistive devices are “task specific,” it is important to state treatment goals as specifically as possible.

Because of the nature of the older person’s vision loss, professionals should become familiar with some key accommodations that assist in providing quality health care, such as the following:

The low-vision eye care specialist (who may be an ophthalmologist or an optometrist) must be flexible and adaptable to a variety of different environments, schedules, and communication styles. The conventional pattern of the low-vision examination will be followed including distance and near acuities; internal and external ocular health examination; retinoscopy; tonometry and slit-lamp biomicroscopy; ophthalmoscopy; ophthalmometry; determination of central and peripheral fields; color vision and contrast- sensitivity testing; glare testing; and near and distance testing of vision- enhancing devices, including optical, electronic, and nonoptical devices. For many older adults, especially those in long-term care facilities, a careful refraction and update of conventional spectacles may provide significant improvement in vision. Table 33-4 summarizes the aspects of the clinical low-vision examination.

TABLE 33-4 ¦ CLINICAL LOW-VISION EXAMINATION

Because of the nature of medical and long-term care service delivery to older adults, the low-vision examination and therapeutic intervention is often taken out of the office or clinical setting. There is a growing trend of providing low-vision services as a part of outpatient hospital care, comprehensive outpatient rehabilitation facilities, and long-term care facilities, such as nursing homes and private homes of older adults.

Despite the fact as many as half the people in nursing homes have visual impairment, few nursing home residents receive low-vision care. For example, one study estimated only 25% of visually impaired patients at a long-term care facility who could potentially benefit from vision rehabilitation were referred for these services. Another study found that there was no difference in the referral rate for vision services for nursing home residents between those who complained about their vision and those who did not. Another study found that only 11% of all residents in 19 nursing homes had received eye examinations in the last 2 years. Providing

The use of curricular materials by long-term care staff has proven effective in increasing staff knowledge and positive outcomes for patients.

Low-vision care is routinely provided to older veterans in the hospital system of the Veterans Health Administration (VHA). In the inpatient Blind Rehabilitation Centers, a veteran who is severely disabled is seen for up to 10 weeks of rehabilitation, including low-vision rehabilitation. Results from a national outcomes study indicate positive outcomes and veteran satisfaction from these programs that exceed the outcomes of rehabilitation in the private sector. The VHA also provides low-vision rehabilitation for veterans who are visually impaired but have remaining vision. In 2009, the VHA expanded low-vision services at medical facilities and in patients’ homes providing

$40 million in funding for a continuum of care closer to veterans’ homes. Outcome studies of all VA vision rehabilitation services indicate that veterans who are provided low-vision services regain their ability to perform independent activities of daily living (IADLs) independently and become active community participants. VHA is the only national medical system that completely integrates vision and blind rehabilitation into the system of care. In fiscal year 2014, VHA provided inpatient, outpatient, and home-based vision and blind rehabilitation to approximately 29,000 unique patients. Further, there are approximately 50,000 severely disabled blind veterans on the rosters of VHA case managers, who assure that this vulnerable population receive all the VA benefits that should accrue to them. Hospitals in the private sector are increasingly providing services to older people as a part of outpatient services, and low-vision rehabilitation is often provided.

The Older Americans Act (OAA) is a major source for the organization and delivery of social and nutrition services for older adults as well as their caregivers. The OAA authorizes many services through a national network of 56 state agencies on aging, 629 area agencies on aging, 244 tribal organizations, and 2 native Hawaiian organizations representing 400 tribes. The OAA programs include community service employment for low-income older Americans; training, research, and demonstration activities in the field of aging; and vulnerable elder rights protection activities. The Administration on Aging (AoA) oversees these OAA programs and services and maintains an online National Eldercare Locator searchable for local agencies and resources. Low-vision services or vision rehabilitation agencies in your area can be located by searching your state’s rehabilitation agency website or searching the American Printing House for the Blind’s Directory of Services (VisionAware: https://visionaware.org/), which includes directories of state agencies, independent service providers, and organizations that provide vision rehabilitation services.

Pew Research Center estimates that 4 in 10 adults in the United States are caring for a sick or older family member at home. The number of caregivers increased 10% between 2010 and 2013; most caregivers surveyed were between 30 and 64 years. Approximately 70% of the older population requiring long-term care resides in the community. Senior residential retirement centers have increased in number. Most frail older people requiring care are living at home with family members and not in long-term care facilities. It is crucial that family members and caregivers understand the sometimes contradictory nature of visual impairment; for example, visual performance varies widely under different levels of illumination and can decline if the older person is fatigued. Comorbid conditions such as dementia, mobility impairment, and depression can affect how the older person uses vision and interprets visual images. Understanding the interaction of these factors will help family members in supporting the older adult achieve their goals for vision rehabilitation.

Whenever possible, a functional assessment should take place in the older adult’s daily environment. Specific goals for using vision independently stated by the older adult will guide the functional assessment to discover what visual target size, target distance, and visual skills are required to achieve that goal. For example, if the patient’s goal is to read the newspaper again, the target size requires approximately 20/40 or better visual acuity with spectacles and magnification, the target distance will be determined by the magnification device, and the visual skills required are precise visual fixation and saccades while maintaining the focal distance of the magnification device. The older adult must learn not only new visual strategies, but also new cognitive strategies to aid comprehension, even with a slower rate of reading. The functional assessment can also uncover the need to address other goals, the need for environmental assessment and modification, and to provide ongoing opportunities to educate the older adult and family about vision and rehabilitation. Table 33-5 presents the key aspects of the functional vision assessment.

TABLE 33-5 ¦ KEY ASPECTS OF THE FUNCTIONAL VISUAL ASSESSMENT

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The functional low-vision assessment may be completed by a wide variety of rehabilitation professionals. Traditionally, the functional low- vision assessment of older people has been provided by a low-vision therapist, a rehabilitation teacher for the visually impaired, an orientation and mobility specialist, or some other professional from the field of visual impairment, such as an eye care technician or technologist. Now, as vision rehabilitation is increasingly a part of hospital services and comprehensive outpatient rehabilitation facilities, the functional assessment may be provided by a rehabilitation nurse, an occupational therapist, or some other rehabilitation professional who has received specialized training in low vision.

Regardless of the background of vision rehabilitation professionals, they should be well versed and experienced in basic optics of the eye, lenses, and low-vision devices; methods of observation and evaluation of visual skills for all daily tasks; the causes and functional implications of visual impairments; basic techniques of sighted guide and basic orientation and mobility; assessment of safety (falls, medication access, sharps, burns, etc); assessment of literacy (reading, numeracy); assessment of the visual aspects of environment; and basic techniques of assessing and using technology such as optical devices (eg, magnifiers, spectacles, monoculars) and electronic devices (eg, Braille writer, smartphones, tablets, computers, and closed- circuit television [CCTV] system). The rehabilitation professional providing the evaluation may also be the rehabilitation therapist, in which case they must be familiar with techniques of instructing visual-motor skills for all daily, vocational and avocational tasks (with and without optical devices and access technology), task analyses, organization and time management, basic orientation and mobility, basic techniques of literacy, and safety in the home. The professional must also be familiar with tools and techniques that do not require the use of vision. There are situations in which using vision is not the safest or most efficient way to complete a task. In that case, other nonvisual strategies such as voice-over, use of Braille tags, use of a long cane on a dark street, etc, are more helpful. The rehabilitation professional will work closely with the eye care specialist providing the clinical low-vision examination, and the low-vision team may also include a counseling professional and any other professionals who are providing care associated with vision impairment or comorbid disabilities. Because many older people are at risk for multiple impairments, this team may also include other

physicians, such as a geriatrician or physiatrist, orthopedist, speech, physical, respiratory, and recreational therapists, nurses, and technicians.

The clinical low-vision examination and functional visual assessment culminate in a vision rehabilitation plan that summarizes the information obtained in the evaluations into clearly stated goals and objectives. If Medicare is funding the low-vision services, the plan will follow that format and requirements. In many cases, family members also may be involved. The implementation of the vision rehabilitation plan should emphasize a process using the principles of andragogy, or adult learning, that incorporate the older person’s values, beliefs, attitudes, and life experiences.

Following the clinical examination and functional assessment, the low- vision team will recommend low-vision devices (including optical, electronic, nonoptical, and environmental modifications) that will be evaluated to assess their usefulness by the older adult. There should be additional focus on the rehabilitation program and its adaptation for older individuals. Successful use of low-vision devices is related to the intensity of the instructional program. Research shows that specialized therapy in the use of visual skills and low-vision devices improve the abilities of low- vision individuals who are older to a greater extent than do the services provided by eye care specialists alone.

Low-vision therapy is a crucial aspect of providing care. Therapy is dependent on the goals of the older adult and might include the following:

Working with a low-vision therapist will provide an opportunity for the older adult to develop the appropriate visual skills; use optical devices and access technology; and learn to apply principles of color, illumination, and contrast that make the environment as conducive as possible to the use of remaining vision. It is important to assist caregivers in understanding how rehabilitation interventions aid the older adult in accomplishing visual tasks. Family members and caregivers can provide important social support in this

regard, but must understand the process in order to be most helpful. In a study of visually impaired older veterans, a supportive caregiver was the most strongly correlated variable to continued use of low-vision devices 1 to 2 years after they were prescribed. If at all possible, devices should be loaned for use in the daily environment before they are prescribed to assure that they are useful.

Some aspects of instructing the use of vision, prescribed devices, and access technology are particularly important when working with older people with low vision. Because of the potentially devastating consequences of falling, the low-vision therapist must be certain to address safety issues related to using low-vision devices that will prevent falls. Nausea, dizziness, and other aspects of motion sickness can be side effects of using magnification, and reducing them is an important aspect of instruction.

Monoculars and binoculars should be used as spotting devices only, and older adults must never attempt to walk while viewing through them. If the older person’s goal is watching television or spectator sports, binoculars that are spectacle-mounted may be provided and the older person will use them only while seated.

Another factor to be explored in the use of low-vision devices for older adults is hand tremor. Hand tremor may be severe enough that handheld magnifiers or telescopes are not useful. The low-vision team may want to explore spectacle-mounted devices to avoid the difficulty of maintaining focus, if hand tremor is problematic.

Postural support and ergonomic considerations are important to using devices for people who are older. Because of the prevalence of back and neck pain, as well as limited stamina, it is important that the therapist assure the older person to be as comfortable as possible. The low-vision therapist will evaluate and demonstrate the use of appropriate ergonomic devices such as the appropriate chair and table, lumbar and cervical support, footstool, lamps, and reading stands. One study demonstrated that older adults who were supported according to ergonomic standards achieved significantly better reading performance.

Cognitive decline may limit the usefulness of low-vision devices for independent functioning; however, an additional goal can be added for rehabilitation—reducing caregiver burden. Vision rehabilitation for older adults with cognitive decline may include ergonomic solutions for comfort, increasing safety by providing good lighting for ambulation and other visual

tasks, judiciously adding bold color and contrast for cuing activity and movement, and using simple assistive devices for common activities (eg, watching television on a larger screen, reading large-print books, getting a bright-colored snack from the refrigerator).

Finally, illumination is an important aspect of the instruction. Most older people need more light, but some may be extremely sensitive to light. An evaluation of a variety of lamps and overhead lighting situations is necessary, with the use of illumination controls that are individually recommended such as filters, absorptive lenses, hats with brims, and pinhole glasses.

Low-vision devices are optical devices, electronic devices, lighting devices, ergonomic devices, access technology such as global positioning devices, accessible smartphones and tablets, and other tools that enhance the use of vision. Some devices, such as those optical devices that incorporate refractive correction, require special prescription. Others are simpler, such as lamps, reading stands, or large-print books. During the clinical evaluation and functional assessment, the low-vision team will discover whether magnification, minification, voice-over, or other nonoptical devices (such as large-print books, lamps, reading stands, etc.) will be useful for enhancing the vision. Table 33-6 summarizes the types of devices available and their uses. Devices are prescribed/recommended based on the goals of the older person and most people require instruction and practice in their use.

TABLE 33-6 ¦ LOW-VISION AND SPEECH-OUTPUT DEVICES

Magnification devices may be categorized as four types: relative distance, relative size, angular, and electronic. Relative distance magnification is provided by bringing the device to be viewed closer to the eyes. Often older adults who want to recognize someone will move more closely to the face they want to see, exhibiting this type of magnification.

Spectacle-mounted magnifiers focus the target image, such as print for reading, at ranges closer than the older eye can accommodate, and allow very close distances to be maintained. These lenses must be prescribed by an eye care specialist experienced in low vision in order to incorporate the refractive correction of the older person when required. Typically, these devices require a close focal distance and have a short depth of focus.

Depending on the power and focal distance, they can be used for near tasks such as reading, writing, and viewing photographs.

Magnification may also be provided by stand or handheld magnifiers, which are often more familiar to older adults who may have used them

previously for maps or coins. These devices do not require a close eye-to- lens distance, but the closer to the eye the lens is held, the wider the field of view. Some are available with built-in illumination, which overcomes the problem of illuminating the target the older adult is viewing. Handheld magnifiers require a steady hand to maintain focus and may be fatiguing to use for long periods. Older adults who use stand magnifiers must wear their bifocal correction for visual accommodation, as the lens is set slightly inside the true focal distance of the lens in order to provide a better optical image at the periphery of the lens.

Relative size magnification is used whenever a target to be viewed is made physically larger. Examples of this are magazines and books that are printed larger than normal. Environments such as older adult high-rise apartments or condominiums and planned communities may also use enlarged signage, another example of relative size magnification.

Telescopic devices provide angular magnification by the use of a positive and negative lens in housing (galilean) or by the use of two positive lenses with an erecting prism (keplerian). Older adults may have used monoculars or binoculars in the past for sporting or other events and may have developed basic skills in their use. Older adults may use telescopic devices for identifying targets that are further away, such as street signs, sporting events, or television. The telescope may be handheld or may be mounted into spectacles for hands-free viewing. Mounted short-focus telescopes may be used for tasks that are closer, such as reading music from a stand or identifying cards on a table. Some older adults with visual impairment who meet visual and driving requirements may use miniature mounted telescopes (called bioptics) for driving.

The CCTV system, used by people who are visually impaired, is an example of electronic magnification. The CCTV provides a camera to focus on the visual task and the older adult sees the image projected onto an enlarged screened monitor or his television set. The visual task may be reading and writing from a desktop or the camera may be positioned for visual tasks at a greater distance such as seeing the minister and choir at church. The advantages of the CCTV include more magnification than any other device, a wider field of view, and color and contrast enhancement capability. CCTV offers a mechanism for the development of new technologies such as miniaturization, head-worn devices, and contrast enhancement.

Computer configuration with the CCTV can use multiple cameras to provide split-screen images for designing a workstation that simultaneously accesses computer, print viewing, word processing, and distance viewing.

Expanded field devices are helpful to older adults who maintain normal or near-normal acuity while experiencing decreased field of view, such as that caused by glaucoma or hemianopsias. Expanded field devices provide the ability to find targets by increasing the perceived view of a scene. For example, an older adult with restricted fields wishes to find the arriving and departing flight monitors in an airport. By using a field-expansion device, these monitors can be more easily located and the user then moves closer to them in order to read the information without the device if central vision is intact. A reverse telescope functions similar to a peephole in a door, but with better optics. Another type of field-expanding device minifies in the horizontal meridian only. The visual field may also be expanded by the use of base-out prisms incorporated into spectacles. The base-out prism shifts the image in, allowing a small eye movement to see the expanded field. Small mirrors attached to spectacles may also be used for field expansion.

Universal design in small portable electronic devices such as smartphones and tablets has revolutionized the field of vision rehabilitation. These devices are manufactured with sensory access (both vision and hearing enhancements) included in each one manufactured. The visually impaired user merely accesses the settings to turn on magnification or voice- over controls in the device, and then downloads a myriad of applications that provide the ability to ask the current location; use navigation systems; read; capture spoken commands, notes and documents; turn on a flashlight in the device; take a picture and ask what the picture depicts; use a wireless keyboard to use the device as a computer and other activities too numerous to mention. Universal design for access is becoming a marketing strategy for companies; one large cable company recently announced voice-over for navigating channels and finding desired programming. For older adults who are technologically adept, accessible smartphones and tablets are quickly learned and highly used. For older adults who have struggled with computers and other technology such as “smart” microwave ovens, these access devices may be very frustrating. However, even very old adults who are cognitively intact can master these intricate but powerful devices with good rehabilitation techniques.

If a smartphone, tablet, computer, CCTV, or other electronic device is to be used visually, the eye care specialist will assure that the older adult’s vision is best corrected for the viewing distance of the screen. A pair of reading spectacles may be prescribed.

Instruction in the Use of Devices That Enhance Remaining Vision A sequence of instructional procedures covers several areas:

spotting, localization, scanning, tracing, and tracking. Individuals with maculopathy (such as age-related macular degeneration or diabetic retinopathy) may require additional instruction in the development and maintenance of visual skills using the PRL.

Instruction in the use of visual skills with low-vision devices includes integrating unaided visual abilities with the unique demands of a low-vision device such as maintaining the focal distance or focusing the device, and adjusting eye and head movements to compensate for a restricted field of view through the lens. If the individual is using eccentric viewing (the use of a PRL other than the fovea), the instructor assures that the device selected allows the opportunity to maximize field and acuity in the eccentric position.

Reading is a task that is so fundamental to our society and so disrupted by age-related visual impairment that it is the primary goal for vision rehabilitation among older adults. Readers with low vision can develop visual skills that are well-adapted to reading if they receive appropriate intervention. Most readers develop a strong PRL following the onset of central scotoma. The PRL is an area that will take over the function of fixation in an eccentric, nondamaged area of the retina. The reader may require instruction and practice in using the PRL for reading, especially because of the demands of using magnification to compensate for acuity loss. A Swedish study found that 71% of older adults with low vision could read the newspaper following rehabilitation, although at a 3-year follow-up that

number had dropped to 48%. However, the number of fluent readers (70 words per minute or better) had increased from 41% to 48% over the 3-year period. These results indicate that those older adults with vision loss who persevere with rehabilitation strategies are able to continue improving their skills over time. In another study, people with macular loss who had a PRL below the scotoma exhibited faster reading rates, and the size of the atrophic area in the macula was the predominant limiting factor in reading; the larger the atrophy, the lower the reading rate. Reading rate is also related to visual span (number of characters available in the field of view) and the reserves of acuity and contrast sensitivity provided by the visual system and low-vision device. Accuracy of word identification and comprehension of reading, however, can remain near normal for readers with macular loss despite their slow rates. Readers with low vision often supplement visual reading with speech output devices such as spoken computer programs and books on audiotape.

Older adults with low vision can write effectively using a combination of magnification devices, lighting devices, stencils (templates for checks, envelopes, letters, etc. that assure that writing is spatially correct), and pens that provide more visibility.

Older adults who have good computer skills can substitute desktop computer, laptop, or smart phone for most low-vision devices and use the universally designed magnification, voice-over, and/or both to achieve reading and writing goals.

The onset of visual impairment for older adults can make even the most familiar environment seem strange and hazardous. It is important that older adults be oriented to familiar and unfamiliar environments, and that the environment be as “user-friendly” as possible to increase independence and safety. There are a variety of rehabilitation techniques that assist in accomplishing this task. Table 33-7 presents the basic strategies.

TABLE 33-7 ¦ WAYS TO MAKE AN ENVIRONMENT MORE VISUALLY ACCESSIBLE

pleasing and comfortable for older people with low vision. A study exploring these types of lighting in reading lamps found strong preferences among older readers with low vision, but no differences in objective measures of reading performance based on the type of light. Thus, informed reader choice should guide the selection of the type of light for older readers.

Light/dark adaptation is another aspect of environmental lighting that must be considered. Most older people have difficulty traveling from bright areas to dim ones because their dark adaptation is not as efficient as in young adults. People with severely restricted field loss (eg, advanced glaucoma) become functionally blind in dim lighting. Avoiding light/dark areas in the environment such as a bright dining room and dim hallway is helpful. When these areas are unavoidable, the older person could use illumination controls such as sunglasses or brimmed hats to assist with light/dark adaptation.

People with severely restricted visual fields who are at risk for falling when ambulating at night may use lightweight, very bright, portable lamps with long battery life that have been designed for night hunters.

Light/dark contrast is produced by the amount of light that is reflected from different surfaces (a light object is brighter than a dark one). A greater contrast between objects and their backgrounds make them easier to see.

Therefore, providing an area of dark background and an area of light background in the bathroom, kitchen, and bedroom can help a person more easily identify possessions. For example, if a comb and brush are of light color, they may be kept on a dark tray. Most TV remotes are black, so they should be placed on a very light background. Similarly, marking the edge of stairs with contrasting colored tape makes each step more visible.

The ability to identify colors, especially darks and pastels, diminishes with age. Certain visual impairments, especially those that affect the cones, such as macular degeneration, also reduce color vision. However, bright, clear colors can be seen by most older people with low vision. For example, yellow against navy blue is very visible, because it combines both color and contrast cues.

Organization can be extremely helpful for the person with low vision. For example, always making sure that doors are completely open or completely closed, and placing chairs under the table when not used increases the safety of the environment. Organizing and labeling clothing by color and function in closets and drawers and organizing the kitchen can assist an older person in continuing to live independently. Learning new ways of performing daily tasks can make the loss of vision less of a problem in independent living. For example, retrieving a pair of spectacles that have fallen onto a light carpet might be difficult for some older adults. Learning a visual scanning pattern that begins at the site where the spectacles seem to have fallen and then continues in a circular pattern outward until they are found will assist in retrieving them.

Using color coding can be helpful as well. For example, chicken soup cans could be marked with wide yellow rubber bands, and tomato soup cans could be marked with wide red rubber bands. These markers could be quickly identified, avoiding the necessity for identifying the soup with a magnifier each time a can is retrieved from the cabinet. Brightly colored and

nubby stick-on “dots” may be provided that provide both contrast and tactual cues for marking dials, buttons, and controls of appliances.

Even when an older adult with low vision retains useful vision for a wide variety of tasks, it is sometimes helpful to use alternative techniques that do not require the use of vision because vision may not be the most efficient or safest way of accomplishing some tasks. For example, even though an older adult may have useful vision for walking, he may find it best to use a long white mobility cane in order to detect drop-offs, so that vision can be used to seek landmarks for orientation. An older adult with low vision may use speech output (a program that speaks symbols or words) for most computer word processing so that limited stamina for reading and writing may be used for reading mail, which must be done visually. A metal plate called a “flame- tamer” may be placed on the eyes of a gas stove in order to avoid burns in the kitchen. Knowledge of a wide variety of rehabilitation strategies and tools will assist older adults with low vision in developing a repertoire of techniques and devices that allows them to complete tasks safely, efficiently, and effectively.

Orientation to a new setting requires some basic alternative techniques that can be used anywhere. Some older adults may be able to use all of the techniques; some may only need one or two. It is important to remember not to rush the older adult in orientation, whether it is a long-term care facility or physician’s office. These exercises may be repeated as often as necessary.

Teaching family members these techniques may be helpful when new environments come up in the future. Table 33-8 presents an overview of these techniques.

TABLE 33-8 ¦ ORIENTATION TO A NEW SETTING FOR OLDER ADULTS WITH VISION LOSS

Anxiety and depression are common reactions to loss, and age-related visual impairment is complicated by the other losses associated with aging. There

are two schools of thought on the timing of rehabilitation related to adaptation. Some rehabilitation professionals subscribe to a “loss theory” of psychological adjustment. This theory proposes that the person must “die” as a sighted person, and be “reborn” as a visually impaired person, incorporating the visual impairment into the sense of self. According to this theory, attempting rehabilitation would be fruitless until the process is complete. Others subscribe to the theory that anxiety and depression are related to a person’s negative stereotypes about visual impairment and a lack of confidence and motivation to attempt rehabilitation, but that if rehabilitation is successful, depression and anxiety should be reduced.

Older adults may hold many negative stereotypes associated with visual impairment: increased helplessness, inhabiting a world of darkness, increased vulnerability to crime, and the perception that use of devices marks them as different or to be pitied. Older adults with low vision may attempt to pass as fully sighted in order to avoid having others project these negative stereotypes onto them. But attempting to pass as fully sighted may cause other difficulties. For example, older adults with low vision do not recognize faces well, and the lack of a friendly hello when passing acquaintances may be interpreted as unfriendliness. Failure to use alternative techniques for identifying targets and moving in the environment may lead to falls, burns, or other safety hazards.

Support groups and peer counseling for older adults with low vision can be extremely helpful in coping with vision loss. Support groups may be found through local multiservice agencies for people who are visually impaired or may be started by senior citizen’s centers or other groups. Short-term professional counseling in conjunction with rehabilitation may be very helpful.

In a recent study of low-vision device use among veterans, most of whom were older males with macular degeneration, family support was the most powerful predictor of continued use of devices up to 2 years following their prescription. Providing information and support to family members who are experiencing the impact of an older member’s vision loss can be powerful. Visual impairment is experienced by the entire family or caregiving system, not just by the older person, and both social and psychological concerns must be addressed. The loss of vision by one family member can disrupt roles in

the family, create economic demands, and add stress when tasks previously performed by the older adult must be performed by someone else.

For family members who understand the functional implications of visual impairment, understanding the behavior of their older adult with low vision is easier. For example, understanding the effect of changing lighting conditions, the effects of glare, and the adaptation times when traveling from dim light to bright and vice versa, can help explain behaviors like shielding the eyes, shuffling the feet, hesitation, fear of falling, and ceasing previously enjoyed activities. The fact that an older adult with restricted visual fields may pick up a dime from the floor, then bump into a partially open door seems contradictory, but is perfectly explained by the functioning field of view.

Assisting older adults with low vision in continuing social activities, such as hobbies, crafts, games, and traveling can aid them in maintaining important contacts with family and peers. Social support and contact are associated with less depression in older adults with low vision. Support groups can assist older adults with low vision in completing and using their rehabilitation, as well as facilitating adaptation to vision loss. Peer support or mutual aid groups who meet regularly to share their concerns may be especially beneficial for older adults who may be overprotected, abused, or treated paternalistically by those who do not understand visual impairment or aging. Facilitating assertiveness for older adults with low vision is recommended because it is linked to less depression and more social support. Social skill training in assertiveness for older adults with low vision has been shown effective in decreasing depression, and in deriving greater satisfaction in life.

Vision rehabilitation services have been funded through private pay, or through vocational rehabilitation services for individuals who were preparing for the work force. Funding for services to older adults with vision impairment has been a critical health care issue in the United States. Public funding through Rehabilitation Administration Service for the Independent Living Services for Older Individuals Who Are Blind program under the Rehabilitation Act is minimal, with approximately $495 million allocated

nationally in fiscal year 2014. These funds provide services in the traditional “blindness” system—state services or private agencies for the blind. State governments may also allocate funding for low-income older people to receive vision and blind rehabilitation as well.

Prior to 2002, only older veterans with legal blindness who served in the US military and whose disability is service-connected had full access to comprehensive blindness and services through the Department of Veterans Affairs Medical Centers. However, most visually impaired veterans have age-related vision loss and their income is such that a copayment is required from them or from their private insurance carrier. Vision rehabilitation services were developed initially to meet the needs of blinded veterans returning from World War II. Young war-blinded men had few other medical problems, so efforts to rehabilitate them for the work force spawned the professions of orientation and mobility instructors, rehabilitation teachers for the blind, and low-vision therapists in order to meet their unique needs.

Services for veterans who are visually impaired but not legally blind were provided nationally beginning in 2008. This specialized “blindness and low- vision” rehabilitation was not considered part of the broader medical rehabilitation. Credentialing of vision-rehabilitation professionals developed separately from occupational or physical therapists, and their practice was autonomous, requiring neither medical referral nor physician supervision. As a result, many medical professionals are unaware of their services and do not understand the “blindness” rehabilitation system in which their practice began. The Department of Veterans Affairs model of service delivery in vision rehabilitation continues today in the same vein. Services are provided nationally by teams of professionals. Ophthalmologists or optometrists provide the medical eye care services, and the vision and blind rehabilitation professionals are orientation and mobility specialists, rehabilitation teachers, and low-vision therapists. Recently the Department of Veterans Affairs appropriated $40 million to provide vision rehabilitation services in a continuum of care for patients who have low vision as well as those who are blind, in recognition that veterans are aging in place and require services close to home. The vision/blind rehabilitation service in this milieu is also unique in that prosthetic devices are provided. Devices such as magnifiers, telescopes, binoculars, CCTV system, computer equipment, accessible

smartphones, and tablets are dispensed according to Veterans Affairs (VA) policy at no cost to veterans as a part of the VA’s commitment to vision/blind rehabilitation services.

The rise in older adults with low vision has spurred Medicare to produce a national policy of reimbursement as well. In 2002, the Centers for Medicare and Medicaid Services (CMS) released a national program memorandum to alert the provider community that Medicare beneficiaries who are blind or visually impaired are eligible for physician-prescribed rehabilitation services from approved health care professionals on the same basis as beneficiaries with other medical conditions that result in reduced physical functioning. This memorandum was issued in response to the committee report accompanying the FY 2002 Labor/Health and Human Services/Education appropriations bill.

The memorandum further directed that the patient receiving services must have a potential for restoration or improvement of lost functions and must be expected to improve significantly within a reasonable and generally predictable amount of time. The rehabilitation that is covered is to be short term and intense; maintenance therapy is not covered. Applicable Health Care Common Procedural Coding System therapeutic procedures are outlined in the memorandum, as are applicable International Classification of Diseases (ICD)-9 codes that support medical necessity.

The effect of the program memorandum has been to increase the visibility of Medicare provisions for vision rehabilitation, but it is not a national coverage decision. Medicare carriers are not compelled by the memorandum to develop a Local Medical Review Policy as a result, and are still able to deny all claims that the local carrier does not deem medically reasonable or necessary.

In 2003, Congress authorized the Secretary of Health and Human Services to carry out a nationwide outpatient vision rehabilitation services demonstration project. The purpose of the project was to examine the impact of standardized national coverage for vision rehabilitation services in the home by physicians, occupational therapists, and certified vision/blind rehabilitation professionals. The 2003 Demonstration Project did not provide coverage for adaptive equipment (low-vision and blindness devices). The project proceeded for 2 years without clear results. The

outcome of the project was status quo, with no new practitioners added to Medicare for reimbursement in providing care for older people with low vision.

To date, the national funding sources for providing vision and blind rehabilitation care continue to be CMS, Department of Veterans Affairs, and Rehabilitation Services Administration.

Palliative care for older adults with visual impairment may focus on assuring that patients are able to see as well as participate in activities that mean the most to them; continue hobbies and other desired activities that relieve stress and help them to feel that life is as normal as it can be; participate in diversions that may assist in managing pain; participate in spiritual activities such as reading or listening to devotional materials that strengthen faith and may reduce anxiety and depression; and reduce caregiver burden.

In addition to the suggested strategies in the section of this chapter titled “Environments for Older People,” the following considerations may assist patients with visual impairment in palliative care.

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The sense of hearing is unequalled by our other sensory modalities in terms of its sensitivity, dynamic range, and discrimination of the finest nuances in stimuli. It does serve us well through a part of our lifetime, but beginning in our 40s (slightly earlier for men and later for women) our inner ears suffer the influence of aging in a very subtle yet progressive manner. Age-related hearing loss (ARHL) affects most people aged 65 and older and represents the predominant neurodegenerative disease of aging.

(The terms “age-related hearing impairment” and “age-related hearing loss” are interchangeably used in the literature whereby “loss” does not imply a complete loss of hearing but may signify any degree of auditory dysfunction. Individuals with hearing loss are generally referred to as “hard- of-hearing.”)

Hippocrates had already noted deafness to be more prevalent among his older patients and in The Comedy of Errors, Shakespeare’s older merchant, Aegeon, complains of his own “dull deaf ears.” Thus, ARHL or presbycusis is not a disease of modern societies but has been accepted for centuries as one of Lord Byron’s inevitable “woes that wait on age” that it still appears to be today. It was the New York otologist St. John Roosa who first drew the attention of his colleagues to hearing loss of older adults as a medical condition. In 1885 he proposed the name presbycusis that he had coined from the Greek p??sß??, old man, and a???e??, to hear. Systematic studies of the anatomical pathology began in the late nineteenth century, leading by the 1930s to the realization that the decreased auditory acuity could be attributed to deterioration of the auditory sensory cells and the auditory nerve. These

changes frequently affect the perception of the upper frequencies first, resulting in high-frequency (high “pitch”) hearing loss as a hallmark of presbycusis. However, ARHL is not a uniform condition, but a multifactorial one combining genetic predispositions with a plethora of lifetime insults to the hearing organ because, in all its versatility and efficacy, our sense of hearing is also uniquely vulnerable to environmental influences. These may include noise, chemicals, and solvents at the workplace, lifestyle (eg, smoking), and leisure activities (from iPods to rock concerts and target shooting), diseases (eg, diabetes, respiratory disorders), viral or bacterial infections, and even the adverse effects of the very medications (aminoglycosides, cisplatin) designed to cure diseases and infections. This spectrum of potential abuse of our auditory organ yields an exceedingly intricate etiology and pathology of hearing loss in older adults. Age-related pathology of the central auditory system adds to the complexity of the problem. Consequently, presbycusis has been defined as hearing loss associated with various types of auditory dysfunction, peripheral or central, that accompany aging and that cannot be accounted for by extraordinary ototraumatic, genetic, or pathologic conditions.

Animal models provide hope to resolve some of the basic mechanisms that underlie the deterioration of hearing and point to ways and means to delay or prevent presbycusis. By virtue of the availability of molecular and genetic information and of transgenic and knock-out animals, mice have become one of the preferred model animals although, as we shall point out later, caveats do apply here too. This review will illustrate the features of human presbycusis and draw on animal models to discuss its potential molecular basis.

ARHL is the most frequent sensory loss in older adults and the prevalence of the disorder increases with age. In humans, as in most other species, ARHL mostly begins at the high frequencies and progresses gradually into the lower speech range. Males experience ARHL earlier than females, beginning in the late 30s to early 40s while women will match the men’s deficits in the later decades of their lives. Approximately 44% of people suffer from a significant hearing loss in their 60s; this number rises to 66% between the ages of 70 and 79 years, and skyrockets to 90% after age 80. With an increased life span of the population worldwide, especially in developed countries, the impact of ARHL will continue to increase in the future.

The individual rate of decline in hearing, however, is exceptionally variable and some people may maintain excellent hearing with “golden ears” late into life as a result of genetic traits that have yet to be elucidated.

Superimposed on the gender differences, race apparently also plays a role, although whether this role is causative or correlative is unknown. One study of over 2000 older Americans aged 73 to 84 found the incidence of high- frequency hearing loss to be 92% in Caucasian American men, 76% in African-American men, 74% in Caucasian American women, and 59% in African-American women.

The large variability in the age of onset, rate of progression, and the nature and severity of the hearing loss suggests that ARHL is a complex genetic disorder with superimposed environmental and health-related risk factors.

Family history plays a role in predisposition to presbycusis. An analysis of hearing thresholds in sibling or parent/child pairs versus spousal pairs (controls) in Framingham Heart Study patients found that the inherited genetic effects were significant. The predictive power of family history appeared stronger for females than males and stronger for a “flat” rather than sensorineural high-frequency type hearing loss (see the classification of age- related hearing loss in the section on “Peripheral Pathology of Age-Related Hearing Loss in Humans”). Overall, the study suggested that about 55% of ARHL in older adults can be ascribed to heritability.

Further studies detailing genes that contribute to ARHL in humans have pointed largely those involved in detoxification of reactive oxygen species (ROS) and include glutathione S-transferase polymorphisms (in the GSTM1 and GSTT1 genes), an N-acetyltransferase 2 gene polymorphism, and superoxide dismutase 2 promoter variants. A genome-wide association study (GWAS) of presbycusic subjects at the Audiological Center of the Antwerp University Hospital found no variants with genome-wide significance.

Previously reported genes for ARHL could not be confirmed, indicating that ARHL is highly polygenic in nature, with probably no major determining genes involved.

The fact that ARHL sets in earlier in males than in females is seen both in the human population and in experimental animals. Differences between males and females diminish in the later decades of life, suggesting a modulation of ARHL by the hormonal status of an individual. In support of this notion, receptors for steroid hormones have indeed been located in the cochlea. In further support of a link between ARHL and hormonal levels, fluctuations in hearing thresholds have been observed during the menstrual cycle; estrogen therapy slowed the development of ARHL in postmenopausal women.

Furthermore, in patients (and mouse models) with Turner syndrome who synthesize inadequate levels of estrogen, ARHL sets in early and sensorineural hearing loss often presents in childhood. While estrogen seems to be protective of hearing, progesterone replacement is detrimental in postmenopausal women, negatively affecting the auditory nerve pathway and neurotransmitters. Generally, sex-hormone replacement therapy in premenopausal, perimenopausal, and postmenopausal women has revealed a number of serious side effects in addition to hearing loss, including strokes, breast and ovarian cancer, and cardiovascular problems.

Another class of steroid hormones, mineralocorticoids, may also influence ARHL. A correlative study in human subjects showed a protective effect of elevated serum levels of aldosterone on auditory thresholds and an improvement of speech perception (“hearing-in-noise”) in older individuals. Although aldosterone primarily acts on water and ion resorption in the kidney, aldosterone receptors have also been localized to the inner ear. They are hypothesized to influence the ionic composition of inner ear fluids, which is essential for cochlear homeostasis and the transduction of sound (see section on “Anatomy of the Auditory Periphery”).

A contribution of specific diseases to the rate and severity of hearing loss has long been speculated but firm evidence is challenging to ascertain. The complex etiology of ARHL and the multitude of potential noxious influences renders it difficult to account for all potentially confounding factors in human population studies. Nevertheless, good evidence exists for diabetes and cardiovascular disease as risk factors in ARHL.

Diabetes mellitus Both type 1 and type 2 diabetes promote hearing loss and cochlear pathology in humans and in animals. Deficits in several aspects of

auditory function were significantly more pronounced in a group of people with type 2 diabetes aged 60 or older compared with a group of age- and sex-matched controls and excluding those with other significant health issues or a history of hearing problems. Furthermore, plasma concentrations of glycosylated hemoglobin (HbA1c), an indicator of potentially elevated glucose levels, have been found to correlate with ARHL in a cohort aged 65 or older, even in those without levels high enough to be diagnosed with diabetes.

Diabetes mellitus and associated deregulated blood glucose levels exact a multitude of stresses on a cellular level, which could lead to loss of function in the delicately balanced hearing organ with time and age.

Fundamentally, increased blood glucose levels lead to cellular hypoxia and a build-up of ROS and lipid metabolic byproducts, as well as changes in the collagen and microtubule structure of the cells. In addition, diabetes has profound effects on the vasculature, including atherosclerosis and vessel wall dystrophy. In the inner ear, which depends on the highly vascularized stria vascularis to maintain the endocochlear potential, this could result in impaired sensory function. Patients with diabetes mellitus also demonstrate abnormal processing of auditory signals at the level of the brain stem and cortex.

Cardiovascular disease All conditions that affect the function of blood vessels such as hyperlipidemia, hypercholesterolemia, hypertension, hyperlipoproteinemia, and cardiovascular disease have been implicated in ARHL. Specifically, a flat ARHL (see next section) appears to be associated with those conditions because the maintenance of the endolymphatic potential and driving force for the transduction process is most vulnerable to any restriction of blood flow. Just as in diabetes, any disease leading to vascular compromise will impair these processes and diminish the sensitivity of the cochlear organ to sound.

Poor health habits with regard to exercise, smoking, and diet are also considered risk factors for ARHL based on data from population studies. Since some of these habits influence cardiovascular function and other potential risk factors for ARHL, it remains open to what extent lifestyle directly influences the auditory organ or whether the resulting effects are secondary to general health. Additional major environmental risk factors

include exposure to excessive or even moderate noise, ototoxic medications (primarily aminoglycoside antibiotics and anticancer agents of the cisplatin class), and several industrial solvents.

Even at levels that do not necessarily inflict acute damage by themselves, these environmental factors appear to sensitize the auditory system to subsequent loss and aggravate any age-related changes. This notion was borne out in experiments in which mice at a young age (1–3 months) received a moderate noise exposure that resulted in temporary hearing loss only.

Although their hearing recovered to normal baseline levels within a few days or a week after the noise exposure, these mice developed a significantly greater hearing loss with progressing age than control animals. Therefore, the initial recovery might not have been a return to normal but to a “hidden hearing loss.” The implication of this finding is that occupational or recreational noise exposure, even if no deficit is noted at the time, will take its toll in later years.

Interestingly, adherence to negative stereotypes about older adults, that is, the concept in many societies that aging is met with an inevitable decline in function of all faculties, demonstrates as a predicting risk factor for ARHL. External stereotyping (the prevalence of stigmata with aging in the individual’s culture) and negative internal perception (extent of internalization of these stigmata) acted as independent risk factors on hearing loss with age, and had a stronger impact than gender or race. This predicts an observable phenomenon wherein cultures with positive concepts of aging do not expect their elders’ hearing to become enfeebled and, in fact, the incidence of ARHL is then lower. Here again, an influence on the auditory system maybe secondary to the effect of stigmata on general well-being and levels of stress hormones in particular. Furthermore, a stimulating social engagement in a positive environment might delay not only cognitive decline but also an associated hearing loss.

In order to understand the different forms of presbycusis and their underlying mechanisms, some knowledge of auditory anatomy and physiology is required. The following sections briefly summarize the essentials.

Not only is ARHL shaped by many influences, it also shows a variety of morphological manifestations. An early framework for classifying ARHL was proposed by Schuknecht in 1964 based on the histopathology of human temporal bones, and has since been modified on the basis of further human and animal studies. The mammalian auditory organ, the cochlea (Figure 34- 1), is encased in bone, and its tissues and fluids coil “snail-like” for 2½ to 4½ turns (depending an species) and a total length of a few centimeters without any relationship to body size. A human cochlea, for example, on average extends for 33 mm in 2½ turns while the dimensions in the guinea pig are 20 mm and 4½ turns. In all species, however, the cochlea is tonotopically organized, meaning that high frequencies are processed in its basal part, low frequencies in the apex.

FIGURE 34-1. Anatomy of the cochlea. A low-magnification light micrograph of a near midmodiolar cross section illustrates the tissues and fluid-filled spaces of the 2½ turns of the mouse cochlea. As indicated in the upper turn, the fluid spaces are the scala tympani and scala vestibuli filled with perilymph, and scala media filled with endolymph. They are separated by the thin Reissner membrane and by the basilar membrane upon which the organ of Corti is located.

When sound reaches the ear, the vibrations of the tympanic membrane (ear drum) are passed along the middle ear ossicles to the cochlea where they initiate a traveling wave in the fluids which, in turn, move the basilar membrane. The tectorial membrane, an acellular structure, rests on the stereocilia of the hair cells. Spiral ganglion neurons run from the organ of Corti where they contact the hair cells through the modiolus to the central auditory system. The stria vascularis and spiral ligament, tissues involved in setting up the ionic composition and high (+70 to +100 mV) potential of the endolymph, lie along the lateral wall of the cochlea.

Several structures with distinctly different functions and susceptibility to environment and age-related insults can be discerned within this membranous labyrinth and are best seen in a midmodiolar section that transverses the length of the cochlea. The lumen of the cochlea is separated into three fluid- filled compartments by the basilar membrane and Reissner membrane. Scala vestibuli and scala tympani contain perilymph, similar in composition to extracellular fluids. Scala media contains endolymph, unique among body

fluids by its high concentration of K+ and low Na+, creating a large positive endolymphatic potential (also referred to as endocochlear potential) as a driving force for the transduction current, which is used by the sensory cells. Scala media is bounded laterally by spiral ligament and stria vascularis, the tissues that are responsible for maintaining the ionic composition and hence the potential of endolymph. These tissues are also highly vascularized and provide most of the oxygen and nutrient supply to the cochlea.

The organ of Corti (Figure 34-2), located on the basilar membrane, is the auditory end organ containing sensory cells and supporting cells. Sensory cells include one row of inner hair cells (IHCs) and three rows of outer hair cells, numbering several thousand in all species. The name “hair cell” is derived from the stereocilia that protrude from the apical end of the cells (Figure 34-3) and contain the mechano-transduction channels. IHCs are the primary sensory cells that convert the mechanical acoustic input into receptor potentials and release of neurotransmitter, triggering action potentials that are carried to the brain by the spiral ganglion neurons (SGNs). Most of the afferent innervation by this auditory nerve converges on the IHCs. The major function of outer hair cells, which receive mostly efferent innervation from auditory centers in the brain, is to enhance the performance of the cochlea, particularly at low intensities of sound. Supporting cells include the inner pillar, outer pillar, Deiters’, Hensen’s, and Claudius’ cells, about whose function we know less.

FIGURE 34-2. The organ of Corti. A cross section shows details of the mouse organ of Corti located on the basilar membrane. The sensory cells are arranged in one row of inner hair cells and three rows of outer hair cells. Inner hair cells are the primary transducers of sound and receive most of the afferent innervation of the spiral ganglion nerve. Outer hair cells amplify transduction and receive most of the efferent innervation. Supporting cells include Deiters’, Hensen’s, and pillar cells. The tectorial membrane does not extend to its full length because of preparation artifacts.

FIGURE 34-3. Hair cells and their stereocilia. A scanning electron micrograph of a “surface preparation” gives a top view of the organ of Corti, presenting the apical aspects of hair cells and supporting cells. The hair cells are distinguished by their stereocilia, the white tufts arranged in linear (inner hair cells, IHC) and W-like (outer hair cells, OHC) form. During sound

transduction, the stereocilia are deflected by a shearing motion generated between the basilar membrane and the tectorial membrane, causing transduction channels to open for influx of potassium from the endolymph. This influx triggers a receptor potential and release of neurotransmitter (glutamate) at the synapse between the inner hair cell and the spiral ganglion nerve. Scale bar: 20 µm. (Scanning electron micro-graph from mouse cochlea kindly provided by Dr. Andrew Forge, Institute of Laryngology and Otology, University College London, UK.)

The cells in the sensory epithelium are highly differentiated. Hair cells, once lost, are not regenerated by other cell types in the mammal but are replaced by permanent “scars” (Figure 34-4). Consequently, any damage to these cells leads to irreversible hearing loss. Considerable research effort is currently expended on determining any factors that might regenerate hair cells from supporting cells or enable the differentiation of putative stem cells into hair cells.

FIGURE 34-4. Loss of hair cells with age. Surface preparations of the mouse cochlea are stained with phalloidin to visualize F-actin, a major component of stereocilia and hair cells. Three rows of outer hair cells are complete and arranged in an orderly fashion in an animal of 3 months of age. At 23 months, the structure is disturbed and some cells are missing.

From a clinical functional aspect, pure tone audiometry, tympanometry, acoustic reflex measurements, and word recognition scores with behavioral tests are the most common and important methods for hearing assessment.

Tympanometry and acoustic reflex (stapedius reflex) test the integrity of the middle ear while audiometry yields information about acoustic thresholds at distinct frequencies. Word recognition tests, in contrast, explore more complex tasks that involve both the auditory periphery and central processing of the information. Auditory brain stem response (ABR) and otoacoustic emission measurements provide information on the integrity of the auditory pathway and outer hair cells, respectively. They are passive sound-evoked responses and therefore suitable for testing infants or incapacitated individuals and most easily adapted to routine testing in animals. Some

invasive methods, essentially limited to animal experimentation, such as recordings of cochlear microphonic potential (largely derived from outer hair cells), cochlear whole nerve action potential, and single unit recordings, can be used to assess hair cell transduction and synaptic activity, the function of auditory afferent nerves, and individual neurons of the cochlear and vestibular nerves.

A significant hearing loss of any origin will eventually lead to difficulties in communication and a decreased awareness of the environment. In addition to the social isolation, individuals with early-onset presbycusis may suffer economic consequences from difficulties in employment or professional advancement. The question of what constitutes a significant hearing loss is complex as it involves consideration of both the magnitude of sensitivity loss and the frequencies at which the loss occurs. Although the most convenient assessment criterion for ARHL is a subjective one—that is, posing the question, “Do you have a hearing problem?” or answering a more elaborate questionnaire like the Hearing Handicap Inventory for the Elderly-Short (HHIE-S)—a more quantitative evaluation can be obtained by an audiogram. While there is not one set paradigm for classification of audiograms into handicapping and non-handicapping hearing thresholds, the American Speech-Language-Hearing Association and the American Academy of Audiology set the bar at a threshold shift (hearing loss) of 25 dB or above at any frequency between 250 Hz and 8000 Hz.

What does a loss of 25-dB hearing acuity mean in everyday terms? The bel or decibel (dB) scale of sound pressure (“intensity”) is logarithmic, such that an increase in 3 dB represents approximately a doubling of the sound intensity. Therefore, a reduction of sensitivity of 25 dB is considerable. In rough terms, a difference of 25 dB in threshold makes normal conversation equivalent to a whisper, and a whisper equivalent to silence (Table 34-1).

The affected person will still hear the crying baby—albeit subdued—but not the leaves rustling in the forest or the crickets in summer.

TABLE 34-1 ¦ TYPICAL SOUND LEVELS

There is one caveat. Defining hearing loss as beginning at a threshold shift of 25 dB in one ear is clinically useful but does not necessarily mean that an afflicted person even notices the deficit. Auditory impairment may be asymmetrical, affecting primarily one ear only (recreational shooters or

combatants are good examples). Such a unilateral impairment might remain unnoticed since the better ear will provide a “normal” hearing in most situations.

ARHL poses a specific problem as the hearing loss progresses slowly and mostly sets in at the high frequencies. The frequency spectrum of human hearing, at its best, ranges from about 60 Hz to 16 kHz but speech frequencies and hence, basic hearing needs, mostly center on the 1000 Hz to 2000 Hz range (Table 34-2). A hearing loss at the very high frequencies may therefore not produce any communicative disadvantages particularly when conversations occur in a quiet environment; even musical instruments have a limited range in their fundamental frequencies.

TABLE 34-2 ¦ FREQUENCY RANGES OF COMMON SOUNDS

Since the progression of ARHL is also slow, the individual maybe unaware of the gradual loss of overtones in speech or instrumental music (which can extend two or three octaves higher than the fundamentals) for a long time. However, losses at higher frequencies like those in ARHL cost the ability to discriminate between many words with f, p, k, s, t, th sounds (see Table 34-2). For example, to a person with high-frequency hearing loss, “sick” and “thick” may be difficult to differentiate, and “three socks” may sound like “free fox” unless the listener has developed the ability to read the speakers lips for supplementary information or can interpret them in context. Such communication errors may seem trivial, but can cause enormous social disability when they happen in work situations or become cumulative.

Audiological examinations routinely include frequencies up to 8000 Hz and could reveal the presbycusic changes although the individual may still be told by the audiologist that their hearing is “normal for the age.” Such a statement should not be taken to mean that a hearing aid is not necessary or not useful. Quite frequently, an individual with a reasonably reliable pure- tone audiogram and good one-on-one communication skills may experience difficulties in speech perception in a noisy environment such as a restaurant, a party, or a conference because high frequencies are essential for auditory discrimination in the presence of background noise. This “party effect” is often the first signal indicative of presbycusis, and such individuals may greatly benefit in their enjoyment of conversation and music by modern hearing aids fitted to their particular needs.

A classification of the various forms of presbycusis has limitations because of the complexity of functional deficits and pathologic changes. However, broad categories of ARHL are as follows: (1) Sensorineural ARHL refers to a primary degeneration of hair cells (“sensory ARHL”) of the organ of Corti that begins in the base, yielding an audiogram that is abnormal only at the high frequencies (Figure 34-5A). Current data suggest that ARHL in humans largely follows such a pattern of a high-frequency hearing loss. A neural component of ARHL mainly reflects loss of afferent neurons while cochlear structures remain relatively normal, leading to a loss of word discrimination ability. In general, aging people lose afferent neurons only slowly and

significant changes in the audiogram may require a loss of up to 90% of neurons. The incidence of purely neural ARHL is therefore controversial. As hair cells degenerate, secondary neuronal degeneration follows, so that the term “sensorineural” ARHL is favored over a separation of sensory and neural ARHL. (2) A “flat configuration” (or metabolic) ARHL shows an audiogram that is significantly depressed at all measured frequencies. It is thought to be caused primarily by a dysfunction of the supporting structures in the cochlea that maintain the endocochlear potential, the driving force for auditory transduction. A decrease of the endocochlear potential will affect the entire cochlea and hence all frequencies (Figure 34-5B). Human and animal studies have connected a metabolic ARHL to pathology of the stria vascularis and the adjacent spiral ligament but a lack of such correlation has been noted in some human temporal bones and points to a potentially more complex etiology. (3) Cochlear conductive ARHL or mechanical ARHL is caused by changes in the stiffness of the basilar membrane. An audiogram of this type shows a linear decline of over 50 dB at all frequencies without degeneration of any cochlear cells or structures. Only a small portion of ARHL is estimated to fall into this category. (4) Mixed ARHL is the overlap of multiple pathologies. About 25% of cases may be of mixed pathology.

FIGURE 34-5. Audiograms of different degrees and configurations of hearing loss. Pure tone audiograms record the auditory thresholds, that is, the minimal sound level necessary to elicit a response in the listener at specific frequencies. Typical audiograms cover the range from 250 to 8000 Hz and the increasing intensity of the sound is plotted downward on the y-axis. A normal ear (Figure 34-5C, right) would yield an audiogram with flat responses around 0 to 25 dB; if

the threshold is increased in an individual, the curve drops lower. Thresholds of 25 to 30 dB suggest a mild hearing loss, while thresholds of 70 dB and above would make average speech inaudible without hearing aids or a cochlear implant. A. The sloping audiogram from a 62-year- old man shows progressive high-frequency hearing loss in both ears. Lower speech frequencies are within normal limits or moderately affected but thresholds in the higher frequencies are sufficiently poor to cause difficulty with speech understanding in background noise B. The flat audiogram from a 64-year-old man shifted to higher thresholds is indicative of a “metabolic” presbycusis. C. The audiogram from a 32-year-old man shows a sharply defined hearing loss of 45 dB only at 4 kHz in the left ear. Such a “notch” in the audiogram is typical for noise damage, here from target shooting or hunting.

In evaluating ARHL, it is oftentimes difficult to determine the individual contributions of environmental influences that might damage the hair cells in the organ of Corti, such as exposure to noise, industrial solvents, or ototoxic medications. Aminoglycoside antibiotics (exemplified by streptomycin, gentamicin, kanamycin, and related drugs), in particular, destroy hair cells in a base-to-apex progression, causing an initial high-frequency hearing loss reminiscent of sensorineural presbycusis. Noise-induced hearing loss usually differs in its pattern as the site of cochlear damage relates to the frequency of the exposure, creating a “notch” in the audiogram. A fingerprint of noise trauma in hunters and shooters, for example, is a unilateral hearing deficit in the 4-kHz region (Figure 34-5C). Damage from industrial noise would be expected to be bilateral and create a broader area of hearing loss.

The recent discovery of a “hidden hearing loss” has spurned an interest in more subtle cochlear morphological changes than overt hair cell loss, in particular the integrity of synaptic connections. SGNs, bipolar cochlear neurons that conduct auditory information to the brain, transmit sound information from hair cells to the central auditory system via two type synapses: cochlear synapses and auditory nerve synapses. The pathophysiology of cochlear synapses at peripheral terminals of the SGNs has been well characterized in animal models: moderate noise exposure can induce loss of IHC synapses as a consequence of excessive glutamate release from overstimulated IHCs (excitotoxicity). This concept is further supported by the protection of cochlear synapses from noise exposure via a blockade of calcium-permeable AMPA receptors that are thought to mediate excitotoxicity. Such damages of cochlear synapses lead to loss of SGNs with aging and accelerate ARHL. This “cochlear synaptopathy” may also occur in humans, as recently revealed in human temporal bones. However, the

prevalence of cochlear synaptopathy is clinically unknown because it is difficult to assess cochlear synaptopathy in patients.

In addition to deficiencies in peripheral auditory processing, advanced age can lead to changes in the central auditory system, which can essentially be classified into two major types. The first is referred to as “peripherally induced central effects,” which presents with changes in the cochlear nucleus driven by the decline of peripheral cochlear inputs that occur with age, typically starting with hearing loss at high frequencies. The other is referred to as “true aging” neurodegenerative changes in the brain. In this case, ARHL shares similarities or common mechanisms with other central nervous system conditions of the aged such as Alzheimer and Parkinson diseases. Age- dependent changes in auditory structures include declines in the number of ventral cochlear nucleus and lemniscal nerve fibers.

Indicative of deficits in sound processing in the higher auditory or cognitive centers, older adults often present with difficulties in speech recognition, rather than an inability to hear sound. Despite audiograms within the normal range, such patients might still require a stronger speech-to-noise signal or might experience better comprehension when speech is slowed down. Specific comprehension tests, for example, of speech perception in noise (QuickSIN test) can be used to better define such a condition, and can often identify difficulties understanding speech in noise independent of degree of hearing loss. Additionally, measures of complex auditory function (eg, speech in noise, comprehension of temporally compressed [“rapid”] speech) have been shown to relate to cognitive measures of working memory in adults. Cognitive screening examinations, such as the Hearing-Impaired Montreal Cognitive Assessment (HI-MoCA) are sometimes used in patients with ARHL in order to parse out contributions of peripheral and central factors to communication difficulties.

Animal models have helped to illuminate some central consequences of degeneration of the auditory periphery. However, the interrelationship of the pathophysiology of the auditory nerve and how it may contribute to central processing deficits in the cochlear nucleus needs further study. With age, synaptic connections may also change in number, spontaneous activity, or in

their inhibitory or excitatory properties. It is possible, although yet unknown, if these changes directly affect speech understanding in humans. For patients with cochlear implants, who often have degeneration of the auditory nerve due to auditory deprivation, we know that the integrity of the auditory nerve matters to optimize speech understanding. Nevertheless, cochlear implants can still be very successful in older patients with a long duration of hearing loss (and loss of peripheral nerve connections) suggesting that the success of cochlear implants and hearing aids is at least partially dependent upon more central factors.

A large variety of species has been studied for age-related auditory pathology, including chinchillas, guinea pigs, primates, dogs, and rodents. These species cover the range of cochlear pathologies, including organ of Corti, neural, and strial degeneration, and the majority of animals show a complex mix. Mongolian gerbils are considered a model for metabolic (strial) presbycusis, presenting with strial atrophy, decreased endocochlear potential, and decreased cochlear blood flow. Degeneration of spiral ganglion cells, vacuolization of fibrocytes, and interstitial edema in the spiral ligament are also observed. In cats and rats, the underlying pathology has been linked to a combination of hair cell and spiral ganglion cell loss.

Recently, a metabolic-type of hearing loss was also observed in the rat underscoring the fact that a singular “pure” type of hearing loss maybe rare in any species.

Mice have become favored for study of ARHL, because of availability of molecular and genetic information and of transgenic and knock-out animals.

A caveat, however, is that each mouse strain differs significantly in its rate of hearing loss, ranging from those such as CBA and CAST, which exhibit minimal hearing loss by 18 months of age, to those such as C57BL/6 and DBA, which exhibit significantly accelerated hearing loss by approximately 8 and 3 months of age, respectively. The accelerated loss of hair cells and hearing found in C57BL/6 and BALB/cJ mice correlates with the presence of a recessive locus on proximal mouse Chr 10, the age-related hearing loss

(Ahl) gene. The Cdh23ahl allele (cadherin 23 or otocadherin) promotes degeneration of the organ of Corti in the cochlear base and high-frequency

hearing loss beginning after 1 year of age as shown in congenic B-6.CAST- Cdh23ahl. Furthermore, Cdh23ahl also promotes noise-induced hearing loss, suggesting a connection between noise and ARHL. Since BALB/cJ and C57/BL mice are genetic mutations, they may not reflect a normal biological

aging process. In fact, one genetic analysis of human presbycusis found no evidence for the presence of a mutation in cadherin 23.

The CBA/J mouse is among the strains in which the progression of ARHL more closely approximates human presbycusis. CBA/J mice lose hearing sensitivity late in their life span, advancing from high to low frequencies. ARHL begins around 12 months of age—here again the onset is earlier in males than in females—and progresses slowly until 18 months, after which point a more rapid rate of hearing loss is seen. The hearing loss at high frequencies is accompanied by loss of outer hair cells and a moderate degeneration of spiral ganglion cells. Since the CBA/J strain maintains normal morphology of the stria vascularis and normal endocochlear potential in aging, a sensorineural origin of the observed auditory deficits can be inferred.

Significant progress has been made in our understanding of the pathologic and functional changes that occur in the inner ear with age using animal models. However, less is known about the specific molecular and genetic mechanisms contributing to ARHL. Recent work suggests to place “auditory aging” in animals—at least for sensorineural presbycusis—into the category of oxidant-stress related events. Oxidant stress is caused by the metabolic overproduction of ROS or reactive nitrogen species (RNS), including singlet oxygen, superoxides, peroxides, hydroxyl radicals, and hypochlorous acid or nitric oxide-derived compounds such as nitroxyl anion, nitrosonium cation, higher oxides of nitrogen, S-nitrosothiols, and dinitrosyl iron complexes.

Maintaining cellular redox homeostasis depends on the rate of production of ROS and their removal by cellular antioxidants. If such homeostasis is disrupted, cell death is a potential consequence. Markers of oxidative stress are indeed elevated in the cochlea of the aging CBA/J mouse while antioxidant defense systems decrease. Other suggestive evidence for an involvement of oxidative stress comes from heterozygous mice lacking superoxide dismutase; ARHL developed earlier and with greater severity, as evidenced by an increased hair cell loss following the canonical base-to-

apex progression. Consistent with oxidative stress is also the observation that the severity of ARHL in humans correlates with plasma levels of hydroxyl radicals and hydrogen peroxide, although a causal relationship cannot be inferred. While oxidative stress may be a contributing factor, failed attempts to slow the progression of cochlear degeneration and hearing loss with antioxidants point to a more complex picture (see section on “Prevention of Age-Related Hearing Loss”). Recent studies in lower organisms suggest that low levels of mitochondrial ROS (mROS) regulate immunity and autophagy, which positively affects aging. The dual function of ROS to both promote cell damage and promote cell adaptation to stress responses makes them challenging as potentially therapeutic targets.

Deletions in mitochondrial DNA are also an established indicator of cumulative oxidative damage to a tissue and have been observed in the aging

—including human—cochlea. DNA in mitochondria, in contrast to nuclear DNA, is particularly vulnerable because these organelles possess less efficient machinery to repair DNA damage, leaving mutations uncorrected and prone to adversely affect mitochondrial function. A mtDNA4977 deletion is the most common mutation found in human temporal bones and

significantly correlated with individual audiometric thresholds and the severity of presbycusis.

Vascular abnormalities are another pathologic change with aging potentially affecting supply of nutrients and oxygen as well as mitochondrial respiration, thus adding to oxidant stress in the inner ear. As a case in point, suppression of cochlear blood flow promotes mitochondrial DNA mutations and may impact hearing loss. In addition, and as already mentioned, reduction of cochlear blood flow from age-related degeneration could lead to a compromised function of the stria vascularis and an inability to maintain cochlear homeostasis for the maintenance of transduction currents and tissue integrity. The sum of these considerations supports the general concept that ARHL is a consequence of accumulated environmental injuries to the cochlea along with the intrinsic genetically controlled aging process.

The majority of so-called mouse models of genetic hearing loss exhibit sensory dysfunction soon after birth; in other words, these are models of accelerated hearing loss not necessarily reflecting human pathology. Hence, the utility of these models for understanding presbycusis-type later-onset

hearing loss is unclear. In contrast, a genetically heterogeneous population of four-way cross mice at the age of 8, 18, and 22 months was tested for auditory hearing function by auditory brain stem response (ABR), and genotyped at 128 markers to identify loci that modulate late-life hearing loss. Polymorphisms significantly affecting hearing at 18 or 22 months of age were noted on several chromosomes. Such phenotypic variability strongly suggests that ARHL is a complex polygenetic disorder possibly involving numerous alleles on multiple genes. These conclusions from an animal model fit well with the previously mentioned GWAS study in humans.

Avoiding noise, ototoxins, and smoking, but engaging in regular exercising and maintaining a healthy diet may aid in slowing progressive hearing loss as it will contribute to general health. The question as to what extent interventive strategies can specifically delay ARHL cannot yet be conclusively answered but some data from animal experimentation point to the general concept that the rate of ARHL can be influenced.

“Augmented acoustic environment” is a concept to influence the progression of presbycusis by exposure to controlled stimuli. This environment could be created by an enhanced ambient acoustic background or by delivery of specific stimuli through hearing aids. Studies in mice, although mostly on inbred strains with accelerated hearing loss, confirm that the auditory system responds to such treatment but not necessarily in predictable ways. While amelioration of some forms of age-related changes was found, other effects were detrimental, leaving final judgment to future experimentation.

Dietary restriction has been widely used in aging studies and can slow certain age-related physiological declines and extend longevity. For the auditory system, results of such studies are inconclusive and emphasize the point that organ-specific effects of a generalized treatment are impossible to predict. Caloric restriction had positive effects on the progression and magnitude of ARHL in rats but was ineffective in rhesus monkeys. A comprehensive study of 15 mouse strains brought every conceivable result from an apparent amelioration of the rate or severity of presbycusis to no effects and to an acceleration of hearing loss. Such results indicate a major influence of genotype on the outcome, cautioning that similar problems might be encountered in presbycusis therapy in humans.

Antioxidant therapy in animal models, based on the premise that oxidant stress is a contributor to ARHL, has shown inconsistent results. Rats that were placed on vitamin supplementation (vitamins C and E) shortly after birth outperformed their placebo controls in hearing tests at old age but the number of animals in this study was exceedingly low and the results might have been skewed by a more robust health of the surviving small cohort.

When the supplementation with antioxidants (acetyl carnitine and lipoic acid) in rats was started later in life and upheld for 6 weeks, results were less convincing. Dogs, on the other hand, fed an antioxidant diet for the final 3 years of their life had better preserved auditory neurons; a confounding factor, however, might have been the high noise level in the kennels which can contribute to noise-induced hearing loss which may be attenuated by antioxidants. In a long-term longitudinal study, 10-month-old female CBA/J mice were maintained on either a control or antioxidant-enriched diet and monitored through 24 months of age; ARHL showed no difference between the two groups. The simple approach to attenuate ROS generation may therefore be an inadequate therapy, perhaps due to the dual role of ROS in adaptation to stress and promotion of cell damage.

Nevertheless, human studies suggest the hypothesis that ARHL can, to some extent, be influenced by dietary or therapeutic intervention. Daily supplementation of folic acid for 3 years positively affected the hearing of older participants in a study in the Netherlands. The effect was significant but very small on low-frequency hearing while age-related changes in high- frequency hearing, the area normally most afflicted by presbycusis, proceeded unaffected. Since low-frequency hearing is important for speech, the result can be considered encouraging. The underlying mechanism of this protection has yet to be established but the effect goes hand-in-hand with controversial observations that patients with higher erythrocyte and serum concentrations of folate maintain lower hearing thresholds. It should be noted however that routine folic acid supplementation of foods is not permitted in the Netherlands but is common in other industrialized countries. Results therefore may differ in countries where basic folate levels in the population can be expected to be higher. Finally and quite intriguingly, several surveys indicate alcohol consumption as a possible modulator of ARHL. Moderate use of alcohol was associated with better hearing in older individuals in three independent studies, an effect in line with—somewhat controversial— observations that low alcohol intake can be beneficial for general health.

Heavy drinkers, in contrast, had a tendency toward more pronounced high- frequency hearing loss.

Restoration of normal hearing is currently not possible since lost hair cells, a major cause of ARH, cannot regenerate. The current choice for rehabilitation of ARHL, therefore, is hearing aids. Digital hearing aids present a wide range of user options and have advanced technologically in all aspects including the tolerance of a noisy environment and improved cosmetology.

Hearing aids, individually tailored to a user’s audiogram, provide clearly increased hearing ability and speech discrimination (Figure 34-6). However, knowledge about the benefits and acceptance of hearing aids is low. About one-half of older people who could benefit from a hearing aid never try; others are dissatisfied after short use and only 10% to 30% continue to wear hearing aids. Rejection to a large extent depends on personal idiosyncrasies, education, and cultural aspects. Health care costs do not appear to be a decisive factor. The compliance rate is the same in the United States (where patients pay or co-pay for the hearing aid) and the United Kingdom (where they are free), around 15%. In some instances the pathophysiological basis may lie beyond the cochlea. “I can hear but I can’t understand” may point to a central auditory deficit that cannot be easily corrected by enhancing the peripheral stimulus.

FIGURE 34-6. Typical effects of a hearing aid. The unaided audiogram (open circles) shows presbycusic high-frequency hearing loss. With hearing aids in place (closed circles), acuity is improved to near-normal levels for frequencies up to 3000 Hz. Note that low frequencies deliberately are not boosted and that rescue of the elevated thresholds at high frequencies is not possible.

If the magnitude of the hearing loss exceeds the corrective capability of hearing aids, cochlear implants (CI) are recommended with increasing frequency to older patients. Cochlear implant candidacy is quickly expanding and is beneficial in patients who score at less than 60% on sentences, in quiet or in noise, in the poorer hearing ear. While a hearing aid essentially amplifies sound to the cochlea and therefore depends on remaining sensory cells, the cochlear implant bypasses the sensory cells and directly stimulates the auditory nerve electrically. To achieve an effective transformation to an electrical stimulus, the acoustic information needs to be preprocessed and delivered to the nerve via an electrode implanted into the cochlea. The success depends on appropriate coding paradigms and a healthy complement of cochlear nerve innervation. Since the degeneration of the cochlear nerve is slow in humans, much of the aging population presenting with presbycusis should be good candidates. The outcome of implantation is variable but almost all of the patients greatly improve speech perception and most even

acquire the ability to carry on telephone conversations. Challenges that remain are speech recognition in unfamiliar contexts and the enjoyment of music. In older patients, cognitive status will also affect cochlear implant outcomes. Unlike acoustic hearing aids, cochlear implants are typically covered by medical insurance (including Medicare) and age is not a contraindication to success. There is some evidence that older patients perform slightly poorer overall with a CI compared to their younger counterparts, but in these patients, it is difficult to parse out effects of chronological age and duration of hearing loss/neural degeneration.

Importantly, CIs are successful and beneficial in the overwhelming number of older recipients.

More recently, there has been a shift in focus and awareness of potential effects of hearing loss on cognitive decline in the aging population. It has long been recognized that even in the absence of significant measurable hearing loss, older individuals demonstrate slowed auditory processing when compared to younger peers. Even older patients with relatively normal hearing can have difficulty understanding speech in the presence of background noise or when the speaker talks at rapid pace; for older individuals with hearing loss, these effects are even more pronounced, and studies have pointed to underlying differences in cognitive processing to help account for senescent declines in speech understanding.

Several studies have identified a potential link between untreated hearing loss and a higher prevalence of cognitive decline in older adults; however, the precise nature or direction of this relationship is yet unknown.

Epidemiologic studies suggest that hearing loss is independently associated with more rapid cognitive decline in older patients, and a single study from Johns Hopkins University (JHU) reported a 24% increased risk for cognitive loss among those with ARHL. Additional studies reveal that the severity of hearing loss also plays a role; among 1103 participants, only those with moderate to severe hearing loss showed an increased risk of cognitive dysfunction compared to normal hearing controls. A radiologic study conducted at JHU reported that even among patients without cognitive loss observed on behavioral screenings, those with hearing loss show changes in

microstructural integrity of the temporal lobe and reduced grey matter in the hippocampus.

It is not yet understood whether hearing aids and/or CIs can be used to help slow the onset of cognitive decline associated with untreated hearing loss. However, a retrospective study at the University of Michigan including 114,862 adults aged 66 or older suggests that the use of hearing aids can delay the diagnosis of Alzheimer and dementia, and also results in lower incidences of anxiety and falls. Additional studies in older patients who use CIs have reported improved performance on behavioral measures of cognitive function, when preoperative and postoperative scores are compared. While studies are underway, there is currently insufficient data using prospective, randomized controls to help determine if hearing aids and CIs can help to prevent early-onset cognitive changes in these populations.

ARHL is an exceedingly complex disease besetting an organ of even greater complexity. It appears to be a sequel to numerous morphological and molecular changes that befall the auditory system as we age and that are being characterized with increasing acuity by basic and clinical research.

One of the major reasons for the lack of treatment of ARHL is the extensive phenotypic variability in hearing loss among human subjects. Our understanding and ability to design interventive and curative therapies will much depend on advances into the molecular and cellular mechanisms of auditory pathologies and identification of genetic variants associated with ARHL. Recent new technologies such as next-generation sequencing including DNA-Seq, RNA-Seq, ChIP-Seq, Methyl-Seq, targeted sequencing utilizing Illumina HiScanSQ, and Ion Torrent instrumentation will provide the platform to perform a large-scale genome-wide phenotype association studies with ARHL.

Given the partial success of pharmacological protection, this approach should yield the first practical results. Appropriate agents for and timing of interventions will be explored in animal models, both independent of and tied into interventions in extending life span and general health. Gene therapy also shows promise as a possible strategy to protect hair cells. To date, research has successfully focused on prevention of hearing loss caused by acute traumata like drugs and noise. Such model systems might be modified to serve hearing loss from aging as the etiology of these insults shows

similarities to age-related sensorineural hearing loss. As a major caveat, any intervention into ARHL would necessitate lengthy trials that may prevent the implementation of prospective solutions in the near future.

In the area of rehabilitation, technological advances of hearing aids and cochlear implants will improve not only speech recognition but also music appreciation, an area currently of difficult rehabilitation. A direct nerve implant, already successfully tested in an animal model, may replace the cochlear implant for better efficacy of stimulation and a wider range of frequency and intensity perception. The following generation of prostheses will bypass the cochlea and its nerve and stimulate higher auditory centers. Although clinical application of auditory midbrain implants is less common, a handful of patients have already been treated albeit with more limited success compared to hearing aids or cochlear implants. Such prosthetic therapy could prove advantageous for patients with massive degeneration of the auditory periphery and/or degeneration of the auditory nerve as in a severe neural type of ARHL.

Recent studies have shown that cells in the organ of Corti, such as supporting cells, may mitose or transdifferentiate into hair cells if appropriately stimulated. The challenges, however, are highly complex: not only hair cells need to be (re)generated, they also have to be incorporated into the intricate cytoarchitecture of the cochlea and find their appropriate connections to the central auditory structures. Stem cell research may likewise provide new insights for replacement of hair cells and the regeneration of the auditory nerve.

Although presbycusis is not yet preventable or treatable, progress in basic and clinical research promises hope for the future. Most realistic in the near term seem protective pharmacological strategies to delay or attenuate ARHL and improved rehabilitation through next-generation hearing aids and implants. A plausible clinical therapy for the regeneration of new and functional hair cells may, despite recent encouraging advance, still be decades away.

The authors wish to thank Andra E. Talaska for her contributions to the previous versions of this chapter. Dr. Schacht’s and Sha’s research on age- related hearing loss was supported by program project grant AG-025164

from the National Institute on Aging, NIH. Dr. Sha’s research is supported by R01 grant DC009222 from the National Institute on Deadness and Other Communication Disorders.

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Gender and Sexuality

Sociological evidence about sexuality of women in middle and later life has increased substantially over the last decade, but sexual function and outcomes among middle age and older women are still largely overlooked in the context of medical care. Negative societal attitudes about aging, sexuality among older people, and women’s sexuality, in particular, present a significant barrier to scientific inquiry and medical attention to older women’s health concerns. Proven interventions for promoting female sexual well-being or treating women’s sexual problems are limited. Although older women experience high rates of sexual problems and the majority of partnered older women are sexually active, physicians infrequently discuss sexual health with older women. Public health attention to older women’s sexuality remains sparse.

Key Clinical Points

Older women, including those without a partner, value their sexual function and expect physicians to counsel them about sexual side effects or expected outcomes of medical conditions and treatments.
An older woman with sexual dysfunction is likely to be bothered or distressed by the sexual problems, and this distress can have deleterious effects on her overall physical and mental health and intimate relationships.
Older women who identify as members of a sexual minority group are marginalized and stigmatized in medical care generally, and they are particularly vulnerable with respect to receiving appropriate medical attention for their sexual concerns.

The 2005–2006 National Social Life, Health and Aging Project (NSHAP), funded by the National Institutes of Health, provided the first comprehensive, population-representative biosocial data on sexuality among middle age and older women and men in the United States, and it informs many of the insights presented in this chapter (https://www.norc.org/Research/Projects/Pages/national-social-life-health- and-aging-project.aspx). In 2010 and 2011 (NSHAP Wave II), 75% of participants in the baseline NSHAP study (Wave I) participated in follow-up interviews. Between 2015 and 2016, 2409 surviving Wave I respondents and an additional new cohort of respondents born between 1948 and 1965 participated in Wave III (accessed at https://www.icpsr.umich.edu/web/NACDA/studies/36873). This chapter first locates older women’s sexuality in a sociodemographic context, then describes sexual activity, behaviors, and problems experienced by women in

later life; reviews physiologic changes that affect sexual functioning as women age; and recommends a clinical approach to evaluation, prevention, and treatment of sexual problems common among older women. Older women, and their sexual relationships, are very heterogeneous.

Generalizations made in this chapter, based on population data from the NSHAP study and findings from other sources, are rooted in statistical norms but should not be interpreted as a normative prescription for older women’s sexuality.

The interactive biopsychosocial model (IBM) provides a conceptual framework for understanding the bidirectional relationship between sexuality and health throughout the life course (Figure 35-1). To the degree that medicine attends to matters of sexuality, the orientation is largely negative.

The medical model approach to understanding sexuality focuses on sexual dysfunction as a problematic consequence of aging, disease, or treatment.

Sexual behavior can result in health problems, such as sexually transmitted infection and victimization. Aging, physical and mental health problems, surgeries, medications, and other medical treatments can cause sexual dysfunction. The IBM acknowledges this reciprocal relationship between sexuality and health but incorporates the possibilities that sexuality may also be health promoting and that aging, or even illness, may confer advantages for sexual life.

In this model, health comprises biological, psychological, and social components and is conceptualized as jointly produced by a woman in conjunction with her spouse or other intimate partner(s). Joint production of health means that partners contribute assets (or liabilities) to the “health endowment,” and these assets and liabilities impact the health of the other(s). The hourglass shape symbolizes the dynamic nature of both health and intimate relationships over time. Clinically, this model can be used as a mnemonic for the broad domains of inquiry pertinent to assessing a patient’s sexual history and reminds the clinician of the importance of ascertaining the presence, and health, of the patient’s intimate partner(s).

Sexuality in later life commonly occurs in the context of a long-term marital relationship. Men are significantly more likely than women to have a spouse or other romantic partner in later life and to be engaging in a satisfying sexual relationship, despite a high prevalence of erectile difficulties. As a result of greater longevity, women, in contrast, are much more likely to experience aging, illness, and death without a partner (Figure 35-2).

FIGURE 35-2. Prevalence of relationships and sexual activity by age and health status. Note: Red symbols denote men; yellow symbols denote women. (Reproduced with permission from Lindau ST, Schumm LP, Laumann EO, et al. A study of sexuality and health among older adults in the United States. N Engl J Med. 2007;357[8]:762–774.)

Still, many older women regard sexuality as important for health and relationships and, among those with a spousal or other intimate relationship, many engage in regular sexual activity. Women tend to be less satisfied with sex in later life than men, and they also report a high frequency of sexual problems including low desire, vaginal dryness, and difficulty experiencing orgasm. An older married woman is often healthier and more vital than her

spouse and commonly assumes a caregiver role, which can interfere with the romantic dynamic of the relationship. Physical health problems, medications, and medical treatments affect the sexual lives of older couples; older heterosexual adults with a spouse or other intimate partner who are not sexually active most commonly attribute this to the male partner’s health problems. Although some aspects of aging are regarded as detrimental to sexual life, older women also identify ways in which aging is beneficial for sexuality (Table 35-1).

TABLE 35-1 ¦ OLDER WOMEN’S VIEWS ON SEXUALITY AND AGING

Lack of formal sexuality education combined with widely restrictive social, religious, and cultural practices around female sexuality during much of the twentieth century have influenced the current generation of older women’s sexual expectations throughout their lives. As a result, many report that they have never discussed nor would they initiate discussion of sexual

matters with anyone, including their spouses. Most older women report that they have never spoken of sexual matters with a physician, yet feel that sexuality is an appropriate issue for physicians to address and that the physician, rather than the patient, should initiate the discussion (Table 35-2). Gender and age differences between women and their physicians can also present barriers to communication about sexual matters. In addition, older women perceive physicians to be poorly trained to deal with patients’ sexual concerns and that physicians presume older women to be asexual or disinterested (see Table 35-2).

TABLE 35-2 ¦ OLDER WOMEN’S PERCEPTIONS ABOUT BARRIERS TO DISCUSSING SEX WITH A PHYSICIAN

Aging of the baby boomers, the generation of the sexual revolution, is increasing demand for medical attention to sexual matters. Although male longevity is expected to increase, older women will continue to outnumber older men through 2050; this presents a significant gender disparity in the opportunity for formation of new sexual relationships in later life and, in some cases, results in multiple women sharing a single male partner. Little is

known about the health implications of emerging trends among older adults including nonmonogamy, rising rates of divorce, unmarried cohabitation, same-sex marriages, and later life dating.

Until recently, most of what was known about sexuality in the context of cognitive dysfunction derived from studies of sexual behavior among people with dementia living in nursing home settings. NSHAP Wave II included the first nationally representative study of sexuality among community-dwelling people with cognitive impairment and dementia. This study found that cognitively impaired men were much more likely than women to be partnered (83% vs 57%), about half of all partnered women and men with cognitive impairment, including 40% of those aged 80 to 91, were sexually active.

Sexual problems, including a lack of interest in sex, were reported by a quarter of men and one in ten women with cognitive impairment. Yet, very few cognitively impaired people had addressed sexual function concerns with their partner or a physician. Because cognitive impairment can impede consent for sexual activity, and an individual’s understanding of sex or ability to express their desire for sex can wax and wane in the course of dementia, it makes sense to include an individual’s wishes for sexual activity in their documentation of advance directives. NSHAP, in fact, reported that 14% of women and 17% of men with cognitive impairment engaged in obligatory sex or sex without feeling aroused. Currently, an estimated 3 million older people with cognitive impairment or dementia are both community-dwelling and sexually active. This number is expected to double by 2050. Best practice for care of older adults with cognitive impairment should include early and ongoing discussion about the effects of impairment on sexual function, sexual behavior (which can include an increase or change in sexual behavior in some cases), and decision making about engaging in partnered sexual activity.

The early literature on sexuality and aging in the nursing home or long-term care setting focused on strategies for staff to restrict this behavior. Residents of long-term care institutions are less likely to be sexually active than community-residing older adults, and they cite lack of partners, lack of privacy, lack of interest, sexual dysfunction, and negative attitudes of staff as

limiting sexual expression. Older lesbian, bisexual, and transgender individuals are at increased risk of stigma and discrimination, especially in settings where the right to privacy is limited.

Increasingly, as a human rights matter, long-term care institutions provide private rooms for residents and have trained their providers to understand and accept sexuality in a respectful manner. Sometimes, sexual relationships form among people with dementia who have, but may not remember, a community-residing spouse. Likewise, community-residing spouses may initiate new intimate relationships while maintaining involvement with and commitment to their institutionalized spouse. The implications of these relationships for health and integrity in later life are a growing reality, but poorly understood and often a cause of distress for families. Sexual exploitation and abuse of older women living in residential facilities (and in the community) are poorly documented, but vulnerability is heightened by cognitive impairment, which can interfere with a woman’s ability to consent to sexual relations.

Palliative care, whether provided in an institutional or community setting, presents another opportunity to address a patient’s capacity for sexual function and fulfillment. Palliation for sexual function could entail providing sex hormone therapy to a patient even if she has a history of an estrogen- sensitive cancer. It could also involve treatment aimed specifically at alleviating nonhormonal causes of dyspareunia, such as timing breakthrough pain medications prior to sexual activity. While some patients bring closure to their sexual lives before entering palliative care, other patients may wish to remain intimate with their partners as long as possible. Optimization of sexual function for older women in palliative care is understudied and often overlooked, but is an area of increasing attention.

Population-based normative data for older women show that sexual activity is largely determined by availability of a sexual partner. Among women aged 57 to 64 in the 2005–2006 NSHAP study, about 85% had a current spouse or other romantic or intimate partner. Nearly all of these relationships were reported as heterosexual, monogamous, and involving sexual activity. The proportion of women with a partner declined with age, because of earlier

male mortality. By age 85, only about 40% of women had a partner, and fewer than 20% of all women engaged in sexual activity.

As compared with findings for younger women, women 57 years and older reported fewer total sexual partners over the lifetime. Most sexually active older women reported that their current relationship was monogamous. In the NSHAP baseline study, nearly 1 in 10 married women and twice as many nonmarried women with a sexual partner believed that their current partner had other sexual partners during the relationship.

In the NSHAP baseline study, 5% of women reported ever having a female sexual partner and only five women (0.3%) reported currently being in a relationship with another woman. Although population data on lesbian relationships at older ages are only just beginning to emerge, estimates from the younger population suggest that women in this study may have underreported same-sex relationships. Qualitative research and clinical experience reveals cases of older women choosing or demonstrating receptivity to intimacy with female partners for the first time in later life.

Some women explain this as a choice caused by the scarcity of males in later life, while others are fulfilling, for the first time, a lifelong interest. The Caring and Aging with Pride study (2010), a national community-based survey of lesbian, gay, bisexual, transsexual (LGBT) aging, found that among individuals 50 years and older, lesbian and bisexual adults were less likely to have a partner or be married than people identifying as heterosexual.

The low representation of sexual minorities in studies of older adults, the frequent exclusion of older adults in studies of sexual minorities, and the lack of inclusion of questions ascertaining sexual orientation in routine research practice render older LGBT adults largely invisible in most research. This invisibility is perpetuated in clinical settings when providers do not ask about sexual orientation and when patients feel unsafe disclosing their sexual orientation. Further research is necessary to understand the barriers to accessing care and the health needs of aging sexual minorities so that culturally competent care and targeted interventions can be delivered. With marriage equality declared a constitutional right, older adults who identify as members of a sexual minority group will be more likely to disclose their status in research, clinical, and institutional living settings.

Among those who are sexually active (defined in the NSHAP study as engaging in “any mutually voluntary activity with another person that involves sexual contact, whether or not intercourse or orgasm occurs” during the prior 12 months), the kinds and frequency of sexual activity in which women engage are similar to those observed among younger women. Most commonly, sexual activity involves vaginal intercourse, hugging, kissing, or other forms of sexual touching, and about 45% of sexually active women engaged in oral sex. On average, the frequency of sexual activity for those with a sexual partner ranges from one to three times per month, similar to that observed among younger sexually active adults. About a quarter of women aged 57 to 85 reported masturbating in the previous year. The prevalence of masturbation among women without a partner is the same as among women with a partner. This is also true for older men (50% report masturbating) and suggests that older adults maintain an individual desire for sexual activity, even in the absence of a sexual partner.

Sexually active life expectancy projects population patterns of sexual activity to estimate the number of years, for any given age, of expected future sexual activity. As calculated based on 1995–1996 and 2005–2006 data, at age 55, sexually active life expectancy is about 16 years for women with a spouse or other intimate partner (Figure 35-3). Among sexually active women, good health was associated with a gain of 3 to 6 years of expected future sexually active life. Communication of normative expectations to patients about the longevity and quality of their sexually active lives assuming good health could motivate patients to stop smoking, adhere to medication regimens, exercise regularly, or engage in other health-promoting behaviors. Further research is needed to evaluate the potential impact of sexually active life expectancy projections on individual health behavior. The sexually active life expectancy measure also quantifies years of sexually active life lost in the absence of knowledge and treatments to preserve sexual function as people age.

FIGURE 35-3. Sexually active life expectancy. (Adapted with permission from Lindau ST, Gavrilova N. Sex, health, and years of sexually active life gained due to good health: evidence from two US population based cross sectional surveys of ageing. BMJ. 2010;340:c810.)

Among sexually active women, approximately half reported having one bothersome sexual problem; almost one-third reported having two. The most common sexual problems experienced by older women are summarized in Table 35-3. Lack of interest in sex, pain with intercourse, unpleasurable sex, and inability to experience orgasm are much more common among older women as compared to men and somewhat more common compared to younger women. Because some sexually inactive women discontinued sexual activity as a result of bothersome sexual problems, the NSHAP baseline study underestimates the prevalence of problems in the whole population. On the other hand, many women engage in sex despite bothersome problems. The rewards or gains of sexual engagement may outweigh the experience of sexual pain or lack of physical pleasure; some women may obligatorily participate in sex to satisfy their partner while others may lack agency to refuse.

TABLE 35-3 ¦ MOST COMMON SEXUAL PROBLEMS AMONG A POPULATION-BASED SAMPLE OF OLDER WOMEN IN THE UNITED STATES (N = 1550)

Problems related to sexuality in later life can result from sexually transmitted infection, trauma, and sexual violence or abuse. These topics are discussed below. Sexual dysfunction, including clinical diagnosis and treatment, is discussed later in this chapter.

Data from the NHANES and the baseline NSHAP study provide the population prevalence of STIs among older women. Overall, the prevalence of most STIs in the general older adult population is very low (< 1% for Chlamydia trachomatis, Neisseria gonorrhea, and syphilis), although rates of some infections may be higher in residential communities or geographic regions with high concentrations of sexually active older adults (eg, Florida and Hawaii in the United States), or in other subpopulations. A prevalence estimate for Trichomonas vaginalis among older US women is not available; late twentieth-century data from Danish and Chinese epidemiologic studies indicate that very few cases occur among women 60 years and older.

Changes in the cervical epithelium caused by loss of estrogen in older women may account for reduced susceptibility to these infections. Although there is no evidence for an epidemic, STI prevalence among older adults is likely underestimated because of lack of uniform tracking systems and under- identification in the clinical setting. One study showed that physicians were likely to counsel older African-American and married women about human

immunodeficiency virus (HIV) and other STIs, but the majority of older women reported that a physician has never initiated such discussion.

Viral infections, including genital herpes simplex virus (HSV) and human papillomavirus (HPV), are the more prevalent STIs among older women.

HSV-2 seroprevalence among men and women 70 years and older based on NHANES III data (1988–1994) was 28%, but women had a higher overall prevalence than men and rates were much higher among African-Americans (74%) and Mexican Americans (45%). High-risk, or oncogenic, HPV (HR- HPV) prevalence among women aged 57 to 85, based on 2005–2006 NSHAP data, was 6% and did not vary significantly across age or racial/ethnic groups. The prevalence of HR-HPV among older women is similar to that documented by NHANES for women aged 50 to 59. HR-HPV is an important factor in both cervical dysplasia and cervical cancer, a leading cause of female cancer death in the world. In the United States, about 20% of cervical cancer cases, but more than a third of cervical cancer deaths, occur in women aged 65 and older. Most screening and prevention strategies, including HPV vaccine, use age-based eligibility criteria that exclude older women.

The rate of new HIV infection among older women in the United States, particularly those of minority racial and ethnic groups, has been increasing over the last several years, due mostly to transmission by heterosexual sex. Mucosal atrophy (vaginal, rectal) related to menopausal estrogen depletion increases an older woman’s susceptibility to mucosal tears and abrasions that can facilitate HIV transmission. In 2010, 27% of Americans diagnosed with HIV/AIDS after age 50 were women. Public health messages regarding HIV/AIDS prevention and detection do not target older women, and physicians rarely offer HIV counseling or testing to this group. The effects of HIV/AIDS and treatments on sexual function among older women have been minimally investigated. Please see Chapter 107 for further discussion of HIV in later life.

Counseling women with new or multiple sexual partners warrants discussion of STI prevention, including education about barrier methods such as male and female condoms and dental dams (for oral sex) (Figure 35-4). Few older adults, including those in nonmarital sexual relationships, report using condoms. Condom use by older couples to prevent STIs may be compromised by the belief that condoms are not necessary if there is no risk

of pregnancy; by changes in male and female physiology that occur with age; and by knowledge, communication, and cultural barriers as seen in younger age groups. A male condom is best applied when the penis is fully erect, but for some older men, full erection may not occur until after coitus is initiated. Female condom use does not require a fully erect penis and may be preferable for some couples.

FIGURE 35-4. Barrier methods of sexual protection. Latex male condom (left), nitrile female condom (middle), dental dam (right).

For women, increased susceptibility to condom-induced vaginal irritation or abrasion may result from vaginal dryness and/or atrophy caused by estrogen depletion. Foreplay is encouraged to stimulate full penile erection and maximal female arousal before attempting vaginal or other penetration. Use of water or silicone type lubricants is recommended to reduce vaginal and vulvar friction in couples using condoms (oil-based lubricants can reduce condom effectiveness). Because they dry quickly, water-based lubricants may actually increase vaginal friction. Condoms with spermicide are not necessary for post-reproductive age women and should be avoided because they have a shorter shelf-life and have been associated with urinary tract infection in younger women. Nonlatex male and female condoms and dental dams are available for individuals with latex sensitivities and allergies, and they have physical and performance properties that some individuals may prefer. Male and female condoms and dental dams are for one-time use only.

Medicare annual wellness visits are an ideal opportunity for physicians to assess their patients’ sexual history, although sexual history-taking is not included in the CMS quick reference document for the annual wellness visit. Medicare does cover HIV testing, and, for at-risk individuals, chlamydia, gonorrhea, syphilis, and hepatitis B tests. People at increased risk of STIs can receive up to two individual 20- to 30-minute, intensive in-person

behavioral counseling sessions each year. These counseling sessions can include education, skills training, and guidance on safe sexual behavior and may help mitigate the competing clinical issues that prevent discussion of safer-sex practices during routine visits.

Early life events, including sexual trauma in the form of abuse, exploitation, genital injury, and rape, can have lasting effects on sexuality and health that persist into later life. Lifetime estimates among older women indicate that 20% to 26% of women experience intimate partner violence; nearly 40% in one study reported that this was severe, including forced sex or sexual contact. In the NSHAP baseline study, 9% of women aged 57 to 85 reported a lifetime history of forced sex (which may or may not have been with an intimate partner); of these, nearly 40% reported that the most recent event occurred at or younger than age 19 and 16% reported that the most recent event occurred after age 40. Sexual dysfunction, particularly conditions such as vaginismus, dyspareunia, inability to experience orgasm, lack of pleasure with sex, and disturbing fantasies are more common among women with a history of sexual trauma, violence, or abuse. In conjunction with medical treatment and/or physical therapy, psychotherapy can be effective in helping women cope with sexual violence and experience positive sexual relationships.

Elder mistreatment, or abuse, discussed in Chapter 48, is defined by the US CDC to include sexual abuse or abusive sexual contact but is not limited to an intimate partner. In fact, lack of a spouse or other partner, cognitive impairment, and institutionalization are risk factors for female sexual abuse and rape in later life. Very little is known about how commonly older women experience sexual violence or abuse; 3% of women aged 60 and older in one study reported having been pressured to have sex in a way they did not like or want since age 55. Few older women report that a physician has ever asked questions to ascertain sexual victimization. There is not sufficient evidence to support the accuracy of existing screening tools to identify abuse in older adults, and studies of interventions to address sexual trauma focus almost exclusively on younger women, perhaps explaining why physicians may feel ill-prepared to screen for victimization among older women.

setting are summarized in Table 35-4 and should be part of routine assessment of the older woman.

TABLE 35-4 ¦ SAMPLE INTIMATE PARTNER VIOLENCE SCREENING QUESTIONS

In acute or emergency care settings, intimate partner violence and sexual abuse should be considered when a woman presents with physical injury, vague symptoms (especially in recurrent visits), acute mental status changes, and/or is accompanied by a partner or other individual who interferes with the patient’s interaction with health care providers.

The Masters and Johnson model of the female sexual response cycle (Figure 35-5A), based on physiologic research initiated in the 1960s with a

convenience sample of local sex workers, other volunteers, and patients presenting for treatment of sexual problems or contraception, remains the most widely represented model in medical textbooks and historically was the foundation for the Diagnostic and Statistical Manual definitions for sexual dysfunction. This traditional, linear model describes four phases of human sexual response: excitement, plateau, orgasm, and resolution (sex therapist Helen Singer Kaplan modified this model in 1979 to include orgasm, excitement, and desire) and illustrates notable differences in female as compared with male sexual physiology.

FIGURE 35-5. A. Masters’ and Johnson’s models of sexual response cycles for females and males. Note: In female sexual response cycle, A, B, and C refer to three different sexual response patterns found in females. B. Adaptation (blue) of Basson’s model (pink) of the partnered female sexual response cycle highlighting features pertinent to older women (blue).

(A, Reproduced with permission from Masters W, Johnson V. Human Sexual Response. Boston, MA: Little, Brown and Company; 1966. B, Adapted with permission from Basson R. The female sexual response: a different model. J Sex Marital Ther. 2000;26[1]:51–65.)

According to Masters and Johnson, the female sexual response is more variable than that of males, and female orgasm may be single and peak-like similar to male orgasm, more gradual or undulating, and/or repetitive during a single sexual encounter. The typical male sexual response is described as much more uniform, peaking in a single orgasm, and includes a latency period during which a subsequent orgasm cannot occur. Arousal for women tends to require direct clitoral or periclitoral stimulation and, for many women, nipple areolar complex stimulation, before, during, and/or after intercourse (which may involve penile-vaginal, penile-anal, oral, or manual penetration) in order to experience orgasm. Sufficient arousal with vaginal lubrication (physiologic or with a lubricant) before vaginal penetration may be particularly important for the older woman engaging in vaginal intercourse with a male sex partner because of reduction in the firmness and fullness of the male erection in later life.

The pattern of female sexual response may vary across time and relationships, although little is known empirically about the physiology of the female sexual response cycle in later life or in the context of very long-term (several decades or more) relationships. Psycho-emotional changes, and changes in physical appearance with age, can negatively or positively affect an older woman’s feeling of attractiveness, and can influence her interest in sex. Some women indicate decreased psychological inhibition about physical appearance or improved self-image with age, both of which can be sexually liberating.

As men age, the sexual response becomes more similar to that of women (a phenomenon some refer to as “feminization of the male sexual response cycle”). Tactile stimulation and foreplay are increasingly important for older male arousal, the time to erection and orgasm is longer, and latency between orgasms (the refractory period) is increased. Because few older men or women are aware of these phenomena, these changes often cause unnecessary anxiety and shame, leading some couples to cease sexual activity as a consequence. The changes to sexual physiology that occur with age may be beneficial to some couples, as the mutual need for foreplay and the longer arousal phase in men makes it easier for some couples to experience

Building on the pioneering work of Masters and Johnson, Basson proposed a widely referenced intimacy-based, cyclical model of the female sexual response that incorporates the quality and duration of the relationship as well as the psycho-emotional component of female sexuality (Figure 35- 5B). In women, sexual desire may occur before or following sexual arousal. This model emphasizes the role of intimacy in generating female sexual desire and suggests that lack of intimacy and unsatisfying sexual encounters can raise the threshold for interest and arousal in a subsequent sexual encounter. Rather than linear and discrete, the phases of the female sexual response are described by Basson as variably overlapping in a way that “blends mind and body.”

Further empirical characterization of the physiology and psychosocial aspects of the female sexual response cycle in later life, including how it might fluctuate within relationships over long durations of time, across relationships, and with aging, is needed both to inform women’s expectations and the clinical approach to older women’s sexuality.

Effects of senescence on the endocrine, neurovascular, musculoskeletal, genitourinary, and gastrointestinal systems are particularly salient to sexual function in later life. Global changes in physical appearance, sensory function (hearing, vision, olfaction, taste, and tactile sensation), cognitive function and memory, and body aromas such as scent, breath, and genital odor can also affect sexual engagement and enjoyment. The female sexual response involves a complex and highly interconnected series of physiologic events connecting mind and body. Disruptions in these physiologic systems

caused by age-related changes, physical or mental illness, or medical procedures and medication use can alter the sexual response and the ability of a woman to derive pleasure and satisfaction from her sexual encounters.

Loss of estrogen due to menopause is a dominant physiologic event that can affect many aspects of older women’s sexual function. Women can live a third or more of life in menopause: the median age of natural menopause in the United States is 51 and average female lifespan is 81 years. Surgical menopause occurs when a woman undergoes bilateral oophorectomy (or loses ovarian function as a result of other interventions such as chemotherapy or radiation) prior to natural menopause. In the NSHAP study, about one in five US women aged 57 to 85 reported a history of surgical menopause.

Women who have undergone bilateral oophorectomy, pre- or postmenopause, also experience an abrupt and irreversible loss of androgen production.

Estrogen is important for maintaining skin, subcutaneous, mucosal (vaginal, bladder, and rectal) and musculoskeletal integrity, the vaginal microenvironment (pH balance and microflora), vascular flow to the vagina and clitoris via regulation of nitric oxide synthase expression, and sensory perception. Over time, low estrogen results in vaginal dryness, loss of epithelial cell glycogen, shortening of the vagina, narrowing of the introitus, thinning of the labia, and diminution of the fat pad underlying the mons pubis. Loss of vaginal acidity results from glycogen depletion and can increase propensity for bacterial vaginitis. Urinary and fecal incontinence can be exacerbated by estrogen depletion and inhibit social and sexual relationships as well as sexual function. The term genitourinary syndrome of menopause (GSM) was adopted in 2014 to encompass the constellation of genital and urinary signs and symptoms attributed to the absence of estrogen and aging (Table 35-5). Maintenance of sexual activity in later life appears to offset some of these local genital changes, in part by maintaining elasticity of the vulvovaginal tissues, pelvic floor musculature, and pelvic joints.

Additionally, sexual activity and other forms of physical contact may mitigate estrogen-related decline in sensory perception and function with age and may play a role in female attractiveness. Exogenous estrogen is approved by the US Food and Drug Administration (FDA) for treatment of moderate to severe dyspareunia in women. Details of estrogen treatment, including a table of

available preparations, and treatment of other genitourinary disorders affecting sexual function are provided in Chapter 36.

TABLE 35-5 ¦ AGE-ASSOCIATED GENITOURINARY CHANGES & SYMPTOMS

Testosterone, along with dehydroepiandrosterone (DHEA), plays an important role in female libido, arousal, genital sensation, and orgasm. Loss of testosterone can exacerbate vaginal mucosal atrophy, thinning of pubic hair, and may compromise an older woman’s sense of general well-being.

Female androgen insufficiency as a treatable condition is controversial. While levels of endogenous androgens have not been found to be predictive of sexual function, a large meta-analysis confirmed that testosterone therapy for low libido was effective in clinical trials involving women with bilateral oophorectomy or total loss of ovarian function, as well as postmenopausal women with or without use of estrogen therapy (estrogen reduces bioavailable testosterone by increasing sex hormone–binding globulin production). However, the FDA has not approved testosterone for this indication. Use of testosterone or DHEA to treat female sexual dysfunction is currently off-label in the United States and most countries, and requires close monitoring for side effects. Although rare, irreversible deepening of the voice and growth of facial hair may occur with testosterone use. In the 2019 Global Consensus Position Statement, an international task force found physiologic dosing of testosterone was not associated with severe side effects; however, long-term safety and efficacy have not been established in postmenopausal women.

Figure 35-6 summarizes central and peripheral hormonal mediators of sexual function (see also Chapter 97). Understanding centrally mediated neuroendocrine changes that occur with senescence is an active area of discovery, focused heavily on understanding cognitive pathophysiology. In women and female animal studies, interest in the cascade of neuroendocrine events resulting in menopause has been similarly driven by an effort to understand the role of sex hormones and hormone therapy in neuroplasticity and degeneration, as well as by efforts to treat female infertility. Application

of this knowledge to female sexual function in later life, particularly sex differences in endocrine regulation of the sexual response cycle, is nascent.

FIGURE 35-6. Central and peripheral effects on sexual function. Note: + indicates a positive effect, - indicates a negative effect, ? indicates the effect is unknown; 5-HT: 5- hydroxytryptamine (serotonin). (Adapted with permission from Clayton AH. Sexual function and dysfunction in women. Psychiatr Clin North Am. 2003;26[3]:673–682.)

Aside from its peripheral effects, estrogen plays an important central role via direct membrane receptor activity and modulation of neurotransmitters.

Estrogen appears to exert neurotrophic and neuroprotective activity in the brain that mitigates hypothalamic damage that occurs with age. Estrogen also interacts with serotonin and norepinephrine metabolism, which may explain the role of estrogen depletion in sleep, mood, memory, and, through these and no doubt other mechanisms, the female sexual response cycle in later life.

The hypothalamic-pituitary-adrenal (HPA) axis mediates the human physiologic stress response and, of course, is the pathway or pacemaker through which sex hormonal regulation occurs. The loss of temporality and pulsatility in HPA neural signaling is a key event in menopause; the dynamics of HPA function over the portion of the lifespan following menopause and the implications for female sexual functioning in later life are much less well- defined. Vasoactive intestinal peptide (VIP), now recognized to play a role in female sexual arousal via vasocongestion of the clitoral tissue, also signals time of day information for central gonadotropin-releasing hormone (GnRH) regulation. Rhythmic synthesis of VIP in the brain appears to wane by middle age in women and may be an important triggering event in the loss of hypothalamic-pituitary-ovarian access coordination required for ovulation and menstruation. The peripheral effects of changes in central VIP metabolism for later life sexual arousal in women are unknown.

Neurovascular physiology, mediated by the sympathetic and parasympathetic nervous systems and a growing list of nonadrenergic/noncholinergic neurotransmitters (eg, nitric oxide and VIP), is particularly important for the arousal and orgasm phases of the female sexual response cycle. Arousal involves vascular engorgement of the genitopelvic organs, including the labia, vagina, and clitoris; lengthening, dilation, and lubrication of the vagina; retraction of the clitoral hood; and tumescence of the clitoris.

Microvascular integrity is important for genital sensation and orgasm. Clitoral sensation, in particular, can be compromised by microvascular disease as seen in chronic smokers and women with hypercholesterolemia or diabetes. Although clinical guidelines for diabetes care in men advise assessment and treatment of erectile problems, clinical guidelines for women do not go beyond screening for sexual dysfunction. Research on effective treatment options for sexual dysfunction among older women with diabetes is needed to inform clinical guidelines. Women with diagnosed diabetes are less likely than men to have discussed sexual problems with a physician and more likely to cease all sexual activity.

Cardiovascular disease can impair women’s sexual function in later life both through psychological and physiologic mechanisms. Although practice guidelines recommend that physicians communicate with patients about the sexual implications of heart disease and potential sexual side effects of treatment, these issues are commonly omitted from counseling, and men are significantly more likely than women to receive such counsel.

Treated and untreated hypertension are both associated with lower rates of sexual activity among older women. However, among sexually active older women, the rate of sexual problems is similar among women with treated hypertension, untreated hypertension, and no hypertension. No one class of antihypertensives has been consistently associated with female sexual dysfunction, particularly in older women. Based on expert opinion, older women with hypertension should be counseled that treatment of hypertension is likely to improve overall sexual function and longevity.

Acute myocardial infarction (AMI) is an important health problem in older women. United States and European practice guidelines state that patients with uncomplicated AMI can resume sexual activity within a week of AMI. Based on the largest study to date of sexual outcomes in AMI among older women, the majority of those who were sexually active before their AMI resume sexual activity within 1 year following AMI. Receipt of

counseling by a physician about resuming sex is the single most important predictor of whether a woman resumes sexual activity after AMI.

Phosphodiesterase inhibitors are used in men to treat neurovascular causes of erectile dysfunction; similar effectiveness has not been found in women. The only FDA-approved device for treatment of female sexual dysfunction, the Eros Therapy (UroMetrics) clitoral pump, may assist some women with microvascular disease in experiencing improved clitoral sensation, vaginal lubrication, and orgasm.

Parity, childbirth-related injury, pelvic or lower extremity trauma, obesity, and sedentariness can compromise the integrity of the vulvar, pelvic floor, and lower extremity musculature, contributing to incontinence and pelvic organ prolapse. Effective contraction and relaxation of the peri-introital, perineal, and pelvic floor muscles are important for penetration, arousal, orgasm, and the relaxation phase following orgasm. Loss of flexibility of hip muscles and compromised stability and mobility of hip joints, commonly experienced by women with arthritis or hip fracture, can interfere with sexual functioning in later life. Skeletal changes in the hips and vertebrae caused by loss of bone density, osteoporosis, vertebral compression and fracture, and arthritis can make vaginal penetration, particularly using “missionary” (female supine with hips and knees flexed) position, difficult and may be accommodated by use of alternative sexual positioning such as side-lying or sex without vaginal penetration. Prevention and treatment of these conditions with attention to maximizing musculoskeletal strength and flexibility can improve overall physical functioning and help preserve sexual capacity for aging women. Endorphin release associated with pleasurable sexual activity may help alleviate musculoskeletal pain.

Although more than a third of women age 65 and older are obese, little is known about the effect of obesity on older women’s sexual function and satisfaction. Research is further complicated by women’s varying self- appraisals of their body size and attractiveness, the frequent co-occurrence of obesity and chronic disease among older women, and the potentially different contributions of abdominal adiposity, generalized obesity, and relative weight gain postmenopause.

Gastrointestinal changes with aging that are most relevant to female sexual function include incontinence of stool and flatus, hemorrhoids, and borborygmi. Anal or stool incontinence typically results in cessation of sexual activity and can be socially isolating. Hemorrhoids can be exacerbated by sexual activity, particularly anal intercourse, and may result in bleeding during or following sex. Borborygmi can be controlled to some degree by timing of meals in relation to symptoms. Constipation can be a cause of dyspareunia; this can be overcome by treating the primary cause of constipation and educating the patient to time sexual activity after moving her bowels. Older women should be screened and evaluated for anal and urinary incontinence, especially those who have ceased and/or wish to resume sexual activity after a hiatus, as both are commonly overlooked as contributors to female sexual function. Treatment should be initiated in order to prevent embarrassing or painful sexual experiences that can be very detrimental to sexual self-image and function.

The vast majority of cancers affecting older women involve treatment with local or systemic therapies that impair or surgically remove the sexual organs. Most women who develop cancer value their sexual function and wish to preserve the possibility of future sexual activity. All women, regardless of age or current partner status, undergoing treatment for cancer should be counseled about the potential effects of cancer or its treatment on future sexual function, and baseline sexual activity and function (prior to cancer treatment) should be documented. Women undergoing pelvic radiation should be offered vaginal dilation therapy to preserve vaginal capacity for sexual activity and future gynecologic examinations. The most common sexual function problems in this patient population include dyspareunia, commonly resulting from or exacerbated by severe vulvovaginal atrophy (VVA), and diminished or no libido. Compromised sexual function and painful or unsatisfying sexual activity may strain intimate partnerships and provoke anxiety about cancer recurrence. Repeated studies show that women with cancer, including older women, believe that physicians should discuss sexual outcomes and side effects of treatment. As in cardiovascular disease, women who report discussing sex with a physician are significantly less likely to avoid sex because of a sexual problem or to exhibit complex sexual morbidity.

There is ample evidence that older women, including those who are not currently sexually active, regard sexual function as an important aspect of health, believe it is appropriate for physicians to discuss sexual issues in the context of medical care, and want physicians to be proactive in counseling about sexual outcomes or side effects of treatment. Avoidance of these matters can be deleterious, particularly for women who identify as a member of a sexual minority group. Geriatricians can signal their openness to all patients by posting commonly recognized symbols such as a rainbow flag or an explicit statement of respect for all human rights (Figure 35-7).

FIGURE 35-7. Examples of image and text indicating freedom from discrimination for lesbian, gay, bisexual, transsexual (LGBT) patients. Front (top left) and back (top right) of brochure for the Program in Integrative Sexual Medicine at the University of Chicago, showing rainbow flag icon indicating that LGBT patients are welcome; bottom: excerpt from patient bill of rights and responsibilities for the Cook County Health and Hospitals System indicating nondiscrimination policy. (Top, Reproduced with permission from anneryanphoto.com. Bottom, https://cookcountyhealth.org/wp-content/uploads/2014-03-27-Pt-Bill-of-Rights_2013-07-11- FINAL-English.pdf.)

Table 35-6 lists basic sexual history questions that can be incorporated into a routine geriatrics encounter and should be tailored to the individual’s needs.

TABLE 35-6 ¦ SEXUAL HISTORY-TAKING AND SEXUAL EDUCATION IN THE ROUTINE GERIATRICS ENCOUNTER

The geriatrician is also encouraged to include on patient self-report or review of system checklists a simple item such as, “Do you have any sexual problems or concerns?” The widely used PLISSIT model or the “therapeutic moment” approach described in Tables 35-7A and B can help guide a preliminary conversation about sexual concerns. When a patient presents with multiple concerns in addition to a sexual concern, the geriatrician should work with the patient to prioritize issues for the current visit, acknowledge the sexual concern, and suggest, if necessary, that the patient return for a visit focused specifically on that issue. The IBM (see Figure 35- 1) provides a useful framework for more in-depth assessment of a patient’s sexual concern. The geriatrician should inquire about the patient’s biological or medical problems, psychological or emotional problems, and relational or social problems. If the patient is in a current relationship, the history should also inquire about the partner’s health in these domains, whether there has been communication with the partner about the patient’s sexual concerns, and whether the partner also has any sexual function difficulties.

TABLE 35-7A ¦ THE PLISSIT MODEL FOR ADDRESSING SEXUAL HEALTH NEEDS

TABLE 35-7B ¦ THERAPEUTIC MOMENT MODEL FOR ADDRESSING SEXUAL HEALTH NEEDS AS FOLLOWS:

Use of terms like “dysfunction,” “normal,” and even “healthy” in relation to human sexuality requires caution and has been criticized, particularly in the feminist and psychology literatures. What is a normal level of sexual desire for older women? Is celibacy unhealthy? Few older women report same-sex partners, so is lesbianism abnormal? Is a distressing sexual difficulty a “dysfunction” or a “normal” response to unhappy circumstances in a relationship? Critiques are rooted in a painful history of sexual discrimination, particularly in the United States, and partially in medical history; as recently as the early 1990s, female sexual dysfunction could be diagnosed as a sexual problem experienced by a woman even if it was only troublesome to her partner. In addition, skeptics of the “medicalization” of female sexuality question how “normal” or “functional” sexuality can be defined as the absence of problems, given the high prevalence of sexual problems in the population.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) updates classification of female sexual dysfunction for clinical diagnosis (Table 35-8). The DSM-5 merges the conditions dyspareunia and vaginismus (classified separately in the DSM-IV) as genitopelvic pain/penetration disorder. Hypoactive sexual desire disorder and female arousal disorder are now defined as female sexual interest/arousal disorder.

Population estimates of sexual problems from the cross-sectional NSHAP study (Figure 35-8) and other studies are useful for quantifying the baseline prevalence of sexual problems in later life, or even bothersome sexual problems, but should not be expected to translate precisely into population rates of female sexual dysfunction, clinically defined. Prevalence estimates for older women can be estimated from prior studies, but are needed for the newly defined classes of genitopelvic pain/penetration disorder and female sexual interest/arousal disorder.

FIGURE 35-8. Prevalence of sexual problems and associated distress among a population- based sample of older women in the United States (n = 1550). Note: Estimates are weighted to account for differential probabilities of selection and differential nonresponse. Data in this graph reflect prevalence among those of 1550 women surveyed in the National Social Life, Health and Aging Project who reported having sex in the last 12 months and having at least one sexual problem. (Data from Lindau ST, Schumm LP, Laumann EO, et al. A study of sexuality and health among older adults in the United States. N Engl J Med.

Sexual dysfunction in later life can be primary, such as a lifelong history of bothersome low sexual desire, or secondary. Secondary causes include (1) interpersonal and personal psychological factors including depression and substance use, (2) biological factors including a wide spectrum of illnesses, injuries, physical disabilities, and their medical and surgical treatments (note that earlier life illness such as cancer and its treatment may have long-lasting effects on sexual function in survivors), and (3) social factors. The patient’s psychosexual history and her current partner’s physical and mental health, medications, substance use, and sexual function must also be investigated in order to gain a full picture of the patient’s sexual functioning and to appropriately tailor therapeutic interventions. Common medications implicated among iatrogenic causes of sexual dysfunction are summarized in Table 35-9. Evidence for the effects of drugs on sexual dysfunction is mixed

overall and very limited with respect to older females, specifically. Treatment of underlying disease and health concerns, including common problems like incontinence, vaginal atrophy, sleep dysfunction, and depression, is an essential first step to addressing sexual function problems. Sexual side effects of medications can be offset by improvement of disease- related symptoms and better overall health.

TABLE 35-9 ¦ DRUGS IMPLICATED IN SEXUAL DYSFUNCTION, ALTHOUGH RESEARCH IS NEEDED TO BUILD THE EVIDENCE BASE FOR THE EFFECTS OF MEDICATION ON FEMALE SEXUAL FUNCTION

Health care providers should routinely inquire about sexual function during visits to normalize the topic and establish a safe space to discuss concerns. Questions to assess sexual dysfunction are summarized in Table 35-10.

TABLE 35-10 ¦ QUESTIONS TO ASSESS SEXUAL DYSFUNCTION IN THE PRIMARY CARE SETTING

Although many adult female sexual function problems have a psychosocial component, a thorough gynecologic physical examination by a skilled practitioner is needed to evaluate for underlying gynecologic pathologies that may be contributing to sexual function issues. Details of the routine gynecologic examination can be found in Chapter 36. A vulvar cotton swab test can be used to quantify and localize vulvar pain, although some have questioned specificity of this test. Graded vaginal dilators can be used to demonstrate to the patient her vaginal capacity and to educate her about

dilation, a useful modality in women seeking to resume sexual intercourse after a long hiatus, in women with vaginal stenosis related to radiation or extreme atrophy, and in women with vaginismus. Using a hand mirror or diagram during the pelvic examination allows the patient to visualize genital findings and the depth of penetration with the examining finger, speculum, or a vaginal dilator. This information can be therapeutic and facilitate education about the patient’s genital anatomy and any physical findings.

Although the evidence base for treatment of sexual problems in women is growing, few studies to date include women 65 years and older. Treatment of many sexual problems benefits from an interdisciplinary approach when possible, including thorough medical evaluation, and in some cases, physical and/or psychotherapy. Despite improved coverage of mental health services for Medicare beneficiaries, very few mental health professionals with expertise in geriatrics are also certified in sex therapy. The overview of clinical management presented here draws heavily on recommendations by the Female Sexual Dysfunction Practice Bulletin (Number 2013) updated in 2019 by the American College of Obstetricians and Gynecologists (ACOG), as well as the International Menopause Society White Paper on sexual well- being after menopause, and uses DSM-5 classifications. It aims to give primary care providers initial treatment options. If available and affordable, referral to a specialist with experience in treatment of female sexual dysfunction may be optimal. Psychotherapy, including couples’ and sex therapy, cognitive-behavioral approaches, mindfulness, and sensate focus techniques have been successfully implemented for treatment of female sexual dysfunction and can be adapted to the needs of older women and couples.

Genitopelvic pain/penetration disorder is more common during and after menopause, exacerbated by thinning of the vaginal mucosa, decreased vaginal lubrication, prolapse of the pelvic organs, and shortening of the vagina caused by natural or iatrogenic loss of estrogen. Pain, attributed to these physiologic changes, is a common reason for cessation of sexual activity among older women and couples. Management involves treatment of the underlying condition, as covered in Chapter 36. Lubricants are typically

used to reduce friction during vaginal or anal penetration in women with dyspareunia and are also available in hundreds of variations over the counter (Table 35-11). Both moisturizers and lubricants may be used in conjunction with hormone therapy. Pelvic physical therapy is an effective modality for treating dyspareunia when there is a pelvic, abdominal, and/or low-back component to the dyspareunia and when vaginismus is present. Vaginal dilation with graded dilators or other devices and behavioral, sex, or couples’ therapy are additional modalities that benefit many women with sexual pain disorders. Although, not FDA approved for treatment of VVA, energy-based laser devices, such as microablative fractional CO2 and

Erbium YAG lasers have shown promising short-term benefit in alleviation of symptoms due to VVA. It is important to note that in 2018 the US FDA issued warnings about injuries attributed to intravaginal lasers used as treatment for VVA.

TABLE 35-11 ¦ OVERVIEW OF VAGINAL LUBRICANTS AND MOISTURIZERS

Management depends heavily on whether the disorder is lifelong or acquired and situational or generalized. Acquired situational orgasmic disorder is most common and occurs in the setting of decreased libido and/or relational strain. Treatment primarily focuses on instruction in masturbation, also known as “sexual skills training.” Because older women, particularly those 75 years and older, report less experience with masturbation (some report they have never masturbated), ability to assess orgasmic ability may be limited. Encouragement to self-stimulate either manually or with a vibrator must take into account the woman’s experience with and attitudes about masturbation. Psychotherapy to assess psychological issues and attitudes regarding orgasm and to complement physical interventions may be necessary. Education about vulvar anatomy, the role of the clitoris in orgasm, and variations in female orgasm may be therapeutic for some women. Women with arousal disorders also commonly have difficulty experiencing orgasm, so evaluation of arousal should be included in women with this complaint.

Sleep dysfunction is a common comorbidity in women with libido, arousal, and orgasm disorders.

Currently there are three FDA-approved medical treatments for postmenopausal women experiencing sexual dysfunction: conjugated equine estrogen, ospemifene, and intravaginal prasterone, as discussed earlier.

Other systemic and local exogenous estrogen products, especially local vulvovaginal estrogen cream and vaginal estrogen tablets and rings, are commonly used off-label to treat dyspareunia in menopausal women.

Hormone products have not been approved for use to treat female sexual interest/arousal disorder, but women treated with these products for VVA may experience improvement in desire and arousal that results from alleviation of dyspareunia. Two pharmaceuticals have been approved for treatment of “hypoactive sexual desire disorder,” a term that was eliminated with the 2013 revisions to the DSM-5: flibanserin, a serotonin agonist/antagonist taken daily by mouth; and bremelanotide, a melanocortin- receptor-4 agonist given as a self-injection as needed before a sexual encounter. Neither drug has been approved for use in postmenopausal women

Androgen therapy, including testosterone and DHEA formulations, is being used off-label in some cases for treatment of sexual interest/arousal disorder. Systematic reviews have not shown efficacy with any of the DHEA

formulations, but testosterone use has shown some benefit. However, side effects can be irreversible and safety is not established in older women.

Tibolone, a synthetic steroid hormone, has been investigated for the treatment of sexual dysfunction in postmenopausal women but evidence of its benefits is limited and it is not approved by the FDA. Treatment of depression can improve sexual desire and interest, but some antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs), can inhibit sexual interest.

There is limited clinical data to inform treatment options for SSRI-induced sexual dysfunction, but decreasing or ceasing the SSRI dose, switching antidepressants, or using bupropion in combination with SSRIs to offset this side effect may be effective for some women.

Off-label use of phosphodiesterase inhibitors has also been tried for women with genital arousal disorder (a very small subset of women with sexual dysfunction); again, safety has not been established in older women and there is no convincing evidence that benefit outweighs risk. Tricyclic antidepressants and anticonvulsants are being used by some practitioners for treatment of vulvovestibulitis (a cause of dyspareunia), but these should be used with caution because of central nervous system side effects that may be exaggerated in older women, particularly those taking other medications.

Funding for intervention research in the area of female sexual dysfunction comes primarily from pharmaceutical sources supporting clinical trials of small numbers of young, healthy subjects followed for brief periods; even studies of postmenopausal women include only small numbers of older women. Building an evidence base is a necessary step to offering safe and effective medical, psychological, and other treatments for female sexual dysfunction in later life. Several drugs for treatment of female sexual dysfunction, particularly sexual interest/arousal disorder, are currently in preclinical and clinical trials. The FDA has held a patient-focused drug development public meeting and scientific workshop on female sexual dysfunction to learn from patients about their perspectives on female sexual dysfunction and the treatments currently available. As more treatment options for female sexual dysfunction become available, an increase in sexual activity among women in later life may occur.

Many aspects of older women’s health have been neglected by researchers and clinicians, including sexuality. Sexual and intimate relationships in later

life can promote health and well-being and sustain a basic human need. Many older women engage in sexual relationships despite sexual problems and pain, while others discontinue sex caused by problems that could be treated. Physicians caring for older women can positively impact their patients’ sexual functioning and overall well-being by initiating and fostering an open and ongoing dialogue about sexual matters in the context of healthy aging or in relation to medical conditions and their treatments. Public health messaging and medical education addressing the continued importance of sexual health discussions past reproductive age could help normalize late life female sexuality and validate older women’s sexual health concerns.

Research is needed to establish trajectories of older women’s sexuality with aging especially among people identifying with racial, ethnic, and sexual minority groups, and to provide an evidence base for diagnosis and treatment of female sexual dysfunction in later life.

We would like to acknowledge Amber Matthews, BA, and Isabella Joslin, BA, research assistants in the Lindau Laboratory at the University of Chicago, for their contribution to the review and synthesis of the literature. Additionally, we would like to acknowledge Amber Matthews for her work on data visualization, figures, and editing.

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The population of older women, generally defined as those greater than 65 years of age, is the fastest growing segment of the US population and as such deserves exceptional medical care from all health care providers. Primary and high-quality preventative care are an important challenge and opportunity for the health care workforce for older women. When gynecologic care is provided by geriatric primary care practitioners, they must be more mindful than ever about risks, symptoms, and unspoken issues. Lifetime risk of a gynecologic cancer (excluding breast cancer) is over 5%, greater than a woman’s lifetime colorectal cancer risk. Pelvic floor symptoms bother at least 40% of women age 70 to 79 and more than 50% of women greater than or equal to 80 years. Sexual problems are prevalent in half of older women who are still sexually active. This chapter seeks to address the most common and important gynecologic and urogynecologic issues encountered in a geriatrics practice, with practical tips and suggestions. Urinary incontinence (UI) is not included in this chapter but is covered in detail elsewhere (see Chapter 47). Topics are presented anatomically, in approximately the same order as a physical examination is approached, along with the major corresponding clinical issues.

Gynecologic history and review of systems and medication list are mainstays of the primary care approach to gynecologic care. This should be targeted to assess cancer and infectious disease risks, to anticipate and interpret

problems, and to promote function and quality of life. If a new patient visit is focused on other concerns, an assessment of vaginal bleeding and pelvic or vulvovaginal pain should be obtained at a minimum, since these are most indicative of urgent issues.

Key points in the gynecologic history and physical examination are listed in Table 36-1. If gynecologic surgery was performed, note the indication. For pain, prolapse, and incontinence surgeries, determine whether symptoms are resolved. Lifetime hormonal status and exposure, family cancer history, and cancer screening since age 55 are important in assessing current cancer risks.

TABLE 36-1 ¦ GYNECOLOGIC HISTORY AND EXAMINATION

Diethylstilbestrol (DES) is an often-forgotten cancer risk factor that should be assessed. It was synthesized in 1938 and prescribed to pregnant women until 1971 in the United States and the early 1980s in some European countries. An estimated 5 to 10 million women worldwide took DES during pregnancy. An increased breast cancer risk has been seen in both women who received DES and their female fetuses exposed in utero (DES daughters). The increased risk of vaginal clear cell adenocarcinoma and cervical neoplasia in DES daughters continues into the fifth decade, but little is known about epidemiology of these conditions in advanced age.

The physical examination serves four main purposes: (1) to understand the patient’s anatomic status, (2) to detect unrecognized problems at an early stage, (3) to detect significant current problems in the cognitively or neurologically impaired, and (4) to provide the patient an opportunity to discuss embarrassing and private issues. A surprising number of gynecologic and urologic symptoms are only voiced or discovered during the pelvic examination, despite a thorough history and review of systems. An annual pelvic examination helps the practitioner assess the condition of the vaginal tissue, the vulva and perineum for any abnormalities that may be present.

Although there is some debate regarding the utility of this examination, assessing the health of the vulva and vagina remains important for primary care providers and gynecologists to provide complete care. Periodic examination of “asymptomatic” but concerned women is indicated. A patient may not be able to articulate the concerns she has. Appropriate speculum size, shape, and use is essential to perform a thorough but painless vaginal examination. Topical lidocaine at the posterior introitus as needed limits discomfort. This can also be applied liberally to the vulva and vagina to facilitate examination in cognitively impaired women. Fecal impaction should be ruled out in older women as a cause of a difficult vaginal examination. Fecal impaction can also compress the urethra and bladder and the surrounding innervation (Figure 36-1), cause urinary symptoms in addition to abdominal discomfort, and requires evaluation of underlying causes as well as treatment. (See Chapter 87, Constipation.)

FIGURE 36-1. Sagittal view of normal pelvic anatomy (A) and fecal impaction (B). Note how a large impaction can compress the bladder, urethra, and surrounding innervation and other tissues.

The American College of Obstetricians and Gynecologists (ACOG) is unique in clearly recommending that “annual examination of the external genitalia should continue” beyond age 65. The utility of annual external genitalia examination may be most important in women who are cognitively impaired. Given the possible association with vaginal cancer, ACOG also recommends continuing annual internal pelvic examinations indefinitely in DES daughters, even those who have had a hysterectomy.

While numerous studies address breast cancer, less is known about the epidemiology of benign breast disease in older women, but it may represent a significant number of primary care encounters. The breast is a complex structure subject to many pathologic conditions, both intrinsic and extrinsic. These may involve skin, connective tissue, ligaments, nerves, vasculature, lymphatics, and muscles in addition to mammary ducts and alveoli.

A clinical breast examination begins with inspection to evaluate overall symmetry and presence of skin changes such as erythema, swelling, and bulging or retraction of the nipple and areola. Palpation should include axillary, supraclavicular, and infraclavicular lymph nodes. Pertinent positive and negative findings should be documented, ideally in all patients, but especially if there is any breast complaint. Symptomatic problems can be

categorized as a lump, pain, nipple discharge, or inflammation and should be evaluated and appropriately documented.

It is important for the clinician to remember that it is not possible to distinguish between malignant from benign or solid from cystic masses by clinical examination alone. However, when combining findings from clinical examination, interpreted in combination with pathology and imaging, one can better evaluate and develop a treatment plan for breast lumps. Evaluation of a lump includes noting the size, position, consistency, and character. Location can be described referencing the areola as a clock face and measuring distance from the areolar border. While a myriad of pathologic entities could result in a breast lump, age is a consistent risk factor for malignancy. All discrete lumps should be evaluated by a breast specialist. The diagnostic mammogram and ultrasound may be performed before or after consultation, per consultant preference. If a lump found by the patient is not palpated by the physician, additional consultation is in order. If both the patient and physician agree that now there is no palpable abnormality, reassessment in 2 months to reconfirm is advisable.

Mastalgia is common and rarely indicates pathology. The prevalence of breast pain is 66% and is higher for women nearing menopause than for premenopausal women. The precise etiology of mastalgia is currently unknown. Mastalgia is generally classified as either noncyclic or cyclic. Noncyclic mastalgia is often focal and does not have any relationship to the menstrual cycle. Focal mastalgia is frequently caused by a simple cyst, but breast cancer can occasionally present as localized breast pain. Thus, careful examination, imaging, and possible needle biopsy should be considered. Of note, cyclic mastalgia is usually bilateral, diffuse, and is most severe during the late luteal phase of the menstrual cycle and is most prevalent in the premenopausal population.

Symptoms may be unilateral or bilateral, intermittent, or persistent, sharp, or aching. Only half of women with significant breast pain seek medical attention. Cancer uncommonly presents with breast pain, and mastalgia is not an indication for a diagnostic mammogram. Focal persistent pain may be associated with cancer in 1% to 3% of patients, but primarily in

younger women. If focal persistent pain is concerning, a diagnostic mammogram and ultrasound can adequately rule out cancer, or the patient may be referred.

Pain sources intrinsic to the breast include fibrocystic disease, duct ectasia, trauma, sclerosing adenosis, and stretching of Cooper ligaments. Conditions external to the breast but perceived as breast pain include costochondritis (Tietze syndrome), cervical radiculopathy, intercostal neuralgia, thrombophlebitis of the thoracoepigastric vein (Mondor disease), herpes zoster, angina, cholecystitis, and hiatal hernia. The affected breast(s) should be palpated to differentiate breast from chest wall pain. If findings are negative and mammographic screening is current, the patient can be offered reassurance and follow up. Interference with activities such as physical contact, sexual activity, exercising, and sleeping may indicate a need for more aggressive pain management, starting with a well-fitted brassiere with good support and nonsteroidal anti-inflammatory drugs or acetaminophen.

Prescription pharmacologic agents for mastalgia have side effects and are supported by limited data. Danazol is the only FDA-approved medication for mastalgia. Tamoxifen has also shown efficacy. However, both of these medications come with significant side effects and are targeted for the treatment of cyclic breast pain, which should not be found in the older population.

Breasts are secretory organs and discharge is a common symptom. Important nipple discharge characteristics are whether it is spontaneous or expressed, unilateral or bilateral, involving single or multiple ducts, and the color. The examiner should try to elicit discharge palpating each breast quadrant from the outside toward the areola, and then gently squeezing the areola. A patient may also demonstrate expressing the discharge. A mass should be ruled out, particularly under the areola. Whereas unilateral, single-duct, spontaneous, bloody, or watery discharge is more concerning for neoplasia, bilateral, expressed, non-bloody discharge from multiple ducts is not associated with cancer. Pathologic nipple discharge is defined as a spontaneous single-duct discharge that is either bloody or serous. The rate of underlying malignancy ranges from approximately 2% for young women with no associated clinical or imaging findings to approximately 20% for older women without associated findings. Most pathologic nipple discharges are caused by benign

intraductal papillomas, which are simple milk duct polyps. Consultation should be obtained for all bloody or recurrent spontaneous discharge. A thick gray or green grumous or purulent discharge may indicate duct ectasia (dilated lactiferous ducts with inspissated secretions) or subareolar abscess. Duct ectasia is also the most common cause of blood-stained discharge from multiple ducts. Duct ectasia is benign but may be excised to rule out underlying cancer. Hyperprolactinemia is rare in older women. A serum prolactin is indicated if galactorrhea is observed or suspected. Eczematous and other skin conditions may imitate nipple discharge.

Inflammatory conditions intrinsic to the breast include duct ectasia, fat necrosis, a ruptured inflammatory cyst, an inflammatory abscess due to obstructed ducts, idiopathic granulomatous mastitis, foreign body, radiation, and inflammatory carcinoma. Smoking, diabetes, and rheumatoid arthritis predispose to abscesses. The most common pathogen is Staphylococcus aureus. Risk factors for methicillin-resistant S aureus include diabetes and residence in long-term care. Most abscesses respond well to drainage and antibiotics. Consultation should be obtained for recurrent or persistent abscess. Conditions extrinsic to the breast that may present with inflammation include metastatic lung cancer, Wegener granulomatosis, sarcoidosis, and other skin diseases.

Perceived “pelvic” pain may arise from any component between the umbilicus and the upper thigh. Bladder pain syndrome, also known as interstitial cystitis (IC), is discussed later in this chapter. A strictly gynecologic cause of either acute or chronic pelvic pain is uncommon in older women except with advanced malignancy. Although many women fear that the pain indicates an ovarian problem, other causes are more likely.

After menopause, the ovaries have decreased to about the size of an almond in its shell and are largely inactive, making painful cysts rare and torsion highly unlikely. Benign ovarian cysts and masses are usually asymptomatic until they are quite large. A complaint of “pain” is not likely to herald a gynecologic malignancy; nonspecific abdominal and pelvic fullness or discomfort are more common descriptions associated with cancer. Infection and neoplasm could be gynecologic causes of acute pain. But a non-

gynecologic cause would be more likely, such as constipation, diverticulitis, herpes zoster, or pelvic insufficiency fracture.

Older women rarely experience the same type of chronic pelvic pain (= 6 months) that plagues women in their reproductive years, with “cross-talk” between pelvic organ structures, pelvic tension myalgia, and central sensitization. POP is a more common ailment in the geriatric population and may cause low back or pelvic pain. Pelvic floor repair with synthetic mesh may result in chronic pain. More likely etiologies of chronic pelvic pain involve the gastrointestinal and musculoskeletal systems. The abdomen, low back, and hips should be evaluated. Myofascial pain with trigger points in the lower abdomen is a particularly notorious pelvic pain impostor. This occurs in 30% of patients with chronic abdominal pain, frequently misrepresented as visceral or functional pain. A finding of myofascial trigger points with the Carnett test (increased point tenderness with partial sit-up tensing the abdominal muscles) does not completely rule out internal causes of pain, but initial treatment of this will clarify the etiology.

Following evaluation of the abdomen, back, bony pelvis, and hips, the pelvic examination should proceed slowly, assessing sensation and tenderness from external to internal. Urethra, bladder, and pelvic musculature can be sequentially palpated. If abdominal pain or tenderness is present, begin the “bimanual” examination of the uterus and ovaries using only the vaginal hand. After assessing cervical, uterine, and adnexal tenderness without abdominal palpation, proceed to bimanual evaluation. If the cause is unknown, repeating the examination at subsequent visits is valuable, as the findings typically vary somewhat. Vulvovaginal pain examination is addressed below.

Normal vulvar architecture consists of labia minora, labia majora, clitoris, clitoral hood, and intact urethral meatus (Figure 36-2). Advanced age and estrogen deficiency may lead to a loss of vulvar architecture, especially of the labia minora. Cherry angiomata and epithelial inclusion cysts on the labia majora are common and not concerning. Asymmetrical pigmented lesions should be noted and considered for either biopsy or follow-up examinations. Punch biopsies of the vulva are simple, rarely become infected, and can be

performed in the office under local anesthesia. Bartholin glands are in the inferior (dorsal) aspect of each labium majus. An asymptomatic Bartholin cyst does not require referral if there is no detectable mass associated with the cyst, but rare Bartholin gland malignancies do occur. Thus, a symptomatic Bartholin cyst or abscess in the postmenopausal woman should be drained and biopsied and consideration given to full excision if symptoms persist.

FIGURE 36-2. Illustration of pelvic examination landmarks and a urethral caruncle.

The hundreds of benign vulvar disorders generally fall into categories of infection, neoplasia, and dermatosis, some of which may reflect systemic disorders. Inflammatory disorders may be difficult to recognize, even by dermatologists, because the warm, moist, frictional environment alters their otherwise typical appearance. Establishing a nomenclature that is both clinically useful and pathologically appropriate is challenging. The current International Society for the Study of Vulvar Diseases (ISSVD) classification relies primarily on histologic morphology (Table 36-2). Realizing its limitations, they have since formulated an approach that allows highly accurate diagnoses with just clinical observations. Estrogen deficiency may increase susceptibility to trauma, irritation, and secondary infection, but is not a primary cause of vulvar problems.

TABLE 36-2 ¦ CLASSIFICATION OF VULVAR DERMATOSES: PATHOLOGIC SUBSETS AND CLINICAL CORRELATES (2006 INTERNATIONAL SOCIETY FOR THE STUDY OF VULVOVAGINAL DISEASE CLASSIFICATION)

Lichen simplex chronicus is characterized as an eczematoid disease of hyperkeratotic, scaling plaques with varying pigmentation that is found to be associated with severe vulvar pruritis. This can be seen in conjunction with other vulvar skin disorders and is ultimately brought on by chronic scratching and subsequent irritation from dermatological and environmental processes. Lichen simplex chronicus is associated with patients who have a history of atopic disease in up to 75% of patients and typically presents later in adult life. The diagnosis of lichen simplex chronicus is based on history of pruritis, typical hyperkeratotic lesions on examination, and vulvar irritation. Biopsy may be done to identify underlying disease such as lichen sclerosus or cultures may be sent to identify yeast. First-line therapies involve treating the underlying conditions, utilization of topical corticosteroids, and even a combination of steroid and antifungal ointments if an underlying yeast infection is suspected. Hygiene measures such as controlling the amount of vulvar wetness and avoiding potential irritants (strong soaps, perfumes, or detergents) are key to cutting down on things that exacerbate and prolong the condition.

Lichen sclerosus is a chronic inflammatory disease that can occur at any age, its highest prevalence being after menopause. It may have an autoimmune etiology and is frequently associated with other autoimmune disorders.

Pruritus is characteristic, but it may be asymptomatic. Typical lesions are porcelain white papules and plaques, often with areas of ecchymosis or purpura. Perianal involvement can create the classic “figure of eight” appearance. In more advanced cases, vulvar architecture is lost, with labial fusion, clitoral hood phimosis, and fissures. Scarring may lead to introital narrowing. The malignant potential of lichen sclerosus is debated but may be as high as 4% to 5%. Biopsy confirmation of the diagnosis and visual inspection at least annually are advisable. Treatment is necessary only to control symptoms. Typical regimens involve moderate strength topical glucocorticoids for at least 4 weeks, then tapering to a lower dosing frequency. A subsequent maintenance regimen of daily or twice-daily emollient may reduce the frequency of symptomatic flares. Estrogen has little or no effect on lichen sclerosus but can improve the resilience of unaffected areas, and estrogen cream can serve as an emollient.

Lichen planus exhibits a wide range of morphologies. Of women with oral lichen planus, approximately 20% to 25% have vulvovaginal lesions. The erosive form may cause pain and vaginal discharge, and lead to agglutination and resorption of labial architecture, rarely with complete obliteration of the vaginal orifice. As with lichen sclerosus, biopsy can be utilized for confirmation of diagnosis and to rule out malignancy. Treatment options include topical or systemic corticosteroids or immunomodulators. Other autoimmune disorders to consider are Zoon disorder (plasma cell vulvitis), Behçet disease, Crohn disease, aphthous ulcers, and Hailey-Hailey disorder (fragile and inflamed vulvar and axillary skin). Psoriatic lesions of the genitalia do not exhibit the silver appearance seen elsewhere on the body, and are more often simply erythematous. There is usually a personal or family history of psoriasis.

The differential diagnosis of genital ulceration includes sexually transmitted diseases, the most common of which in the United States is herpes simplex virus (HSV). Immune suppression, including very advanced age, is a risk factor for HSV infection in the absence of sexual contact, and for herpes zoster of the S3 dermatome. A primary infection is usually accompanied by lymphadenopathy, vaginal discharge, urinary frequency and urgency, and painful ulcers on the labia and/or cervix. Zoster can inhibit detrusor function resulting in an inability to void. Lesions clear more quickly with antiviral agents. Other causes include syphilis, the autoimmune disorders listed above, blistering dermatologic disorders, and of particular concern in older women, excoriated or ulcerated neoplasia.

Vulvar carcinoma is a rare malignancy and represents less than 5% of all cancers in the female genital tract. However, even though vulvar carcinoma remains uncommon, the incidence is increasing with an estimated 6020 new cases of vulvar carcinoma diagnosed in the United States annually and an estimated 1150 deaths from the disease. The average age of diagnosis is 68.7 with 70% of vulvar cancer diagnoses occurring in women over the age of 60.

Squamous cell carcinomas (SCC) of the vulva are the most common histologic subtype, accounting for 90% of vulvar cancers. There are two

distinct pathways involving the pathogenesis of SCC of the vulva and its precursor lesion, vulvar intraepithelial neoplasia (VIN). In the past, VIN included grades 1 to 3, but the nomenclature has recently changed, and VIN now refers only to high-grade lesions of the vulva. Human papillomavirus (HPV)-associated VIN, also referred to as usual type VIN, occurs more frequently in younger women and is mostly associated with the carcinogenic HPV genotypes, most commonly HPV 16. HPV-independent VIN, or differentiated VIN, occurs more frequently in older women and is associated with chronic inflammation that is secondary to underlying dermatologic conditions such as lichen sclerosus or lichen planus. The HPV-associated VIN develops slowly and then will spontaneously regress. On the other hand, the HPV-independent VIN is more likely to progress rapidly to invasive squamous cell cancer. Presentation is often with vulvar burning or pruritus.

Vulvar cancer is surgically staged. The presence or absence of lymph node metastasis is the most important prognostic factor for women with this disease. Five-year survival in the absence of nodal metastasis is 91% compared to only 57% for patients with node-positive disease.

Vulvar melanoma is the second most common type of malignancy of the vulva and makes up 5% to 10% of vulvar malignancies. Many vulvar melanomas occur in the older patient population and is more common in the Caucasian population. Compared to the cutaneous version of melanoma and other mucosal melanomas, the prognosis for women with vulvar melanoma is poor with a 5-year survival rate of less than 50%. Similar to cutaneous melanomas, an approach of wide local excision with sentinel lymph node biopsy has been adopted as the treatment of choice for patients.

To evaluate vulvar or vaginal pain, the perineum from the mons pubis to the anus should be inspected for vulvar architectural changes, which may or may not be pathologic, including fissures, ulcers, erythema, and other signs of inflammation. Palpation of the vulva and around the vaginal introitus with a cotton swab will better establish the location and extent of tenderness than digital palpation. Areas to assess are the base of hymeneal remnants, posterior fourchette, and periurethral Skene glands.

Vulvodynia is chronic vulvar pain that persists for greater than 3 to 6 months in the absence of another clinically identifiable condition. In 2015, the ISSVD updated vulvar pain classifications into two categories: (1)

vulvar pain caused by a specific disorder (infection, inflammation, neoplasm, trauma, hormonal deficiency, neurologic disease, or iatrogenic etiology) and (2) vulvodynia, defined as vulvar pain of at least 3 months’ duration, without an identifiable cause. While the true prevalence of vulvodynia is unknown, estimated prevalence is between 10% and 16% over a woman’s lifetime and tends to be more common in older patients. Women may have both a specific disorder and vulvodynia and may require concurrent or sequential management since vulvodynia is a diagnosis of exclusion.

Vulvodynia may be provoked, unprovoked, or both, and generalized or localized. “Localized provoked vulvodynia” denotes the condition formerly termed vulvar vestibulitis. The suffix “itis” is technically inaccurate as inflammation is not usually present. Pain located specifically in the vestibule is referred to as vestibulodynia. This is not particularly associated with aging or atrophy. This condition is poorly understood and may be frustrating for patients and can be difficult to treat. After ruling out known causes of discomfort (infection, dermatitis, genitourinary syndrome, post herpetic neuralgia, etc.), the approach to continued vulvodynia generally must be multimodal and often interdisciplinary to address physical as well as psychosocial causes and effects. Pelvic floor physical therapy, cognitive behavioral therapy, couples’ therapy, and/or sexual therapy all may be utilized depending on the specific attributes of a woman’s pain and setting in which it occurs. Neuropathy is thought to be one of the many components and may be addressed using antidepressants that modulate serotonin and norepinephrine as well as low-dose tricyclic antidepressants; however, evidence for the most appropriate agent, dose, and duration are limited and often extrapolated from experience with other chronic pain syndromes.

Similarly, other agents such as gabapentin, pregabalin, and carbamazepine may be used as adjunct treatment with physical and cognitive therapies.

Topical estrogen is appropriate to ensure that tissue atrophy is not a contributing factor. Glucocorticoid or lidocaine topical preparations rarely improve symptoms for long duration but are reasonable to try both for the effect of their active ingredients and emollient properties. Persistent symptoms may require coordination of care with a pain management specialist.

Unlike the vulva, the vagina is rarely an isolated source of pain unless the patient is sexually active. Simple postmenopausal vaginal atrophy is usually

asymptomatic, but dyspareunia is common. Dyspareunia evaluation is guided by historical factors such as past sexual experiences, exact symptoms during intercourse, and examination. The anterior, lateral, and posterior vaginal walls and apex should be inspected and palpated as separately as possible. Atrophic vaginitis considerations are presented below. Patients with presumed atrophic vaginitis that has not responded to estrogen frequently have an unrecognized vulvar condition. Isolated vaginal pain in the absence of intercourse should prompt consideration of surrounding organs and structures, including the pelvic floor musculature and urinary and gastrointestinal tracts.

Symptoms of vaginitis, vaginosis, and vaginal discharge overlap with each other and with those of vulvar conditions. A true bacterial vaginitis is uncommon in the absence of an underlying epithelial disorder. Bacterial vaginosis incidence increases with age, but only requires treatment for bothersome symptoms or planned vaginal surgery. Yeast infection incidence declines with age, but antibiotics, diabetes, immune suppression, and estrogen therapy are risk factors. Trichomonas can be carried asymptomatically and occur recurrently without partner treatment.

Coexistence with bacterial vaginosis is common. Either estrogen initiation or replacement of vaginal prolapse with a pessary may cause benign white discharge from an increase in epithelial turnover. Desquamative inflammatory vaginitis is an uncommon cause of discharge, burning, and dyspareunia, and may be a manifestation of erosive lichen planus. Rare causes of purulent malodorous discharge include an enterovaginal fistula secondary to diverticulitis, inflammatory bowel disease, or prior surgery.

Evaluation of vaginal discharge in younger and older women is largely the same except for vaginal bleeding. Any history of a brown or red discharge necessitates endometrial evaluation. Physical examination is essential to evaluate vaginal discharge as findings often differ from the presumption based on history. With aging and estrogen deficiency, vaginal pH rises, providing a less hospitable environment for both lactobacilli and yeast. However, vaginal candidiasis still occurs and stereotypically is accompanied by symptoms of odorless, thick, white discharge and pruritis. The vulva may be involved with erythema, excoriations, and satellite lesions. On microscopy, pseudohyphae are diagnostic. In contrast, bacterial vaginosis

Vaginal atrophy due to hypoestrogenism involves several changes including mucosal thinning; loss of rugae, elasticity, and distensibility; an increase in subepithelial connective tissue and vaginal pH (> 4.5); and reduced secretions which collectively contribute to genitourinary syndrome of menopause. Changes in the vaginal microbiome predispose to urinary tract infections (UTIs). Atrophic “vaginitis” is poorly defined apart from simple atrophy, but is usually diagnosed when symptoms (dryness, itching, irritation, burning, dyspareunia, irritative voiding) or signs (pale, thin, shiny vaginal mucosa, telangiectasias, petechiae, patches of inflammation, discharge) are present (Figure 36-3). A cytologic maturation index would reveal 60% to 100% parabasal cells but is not necessary for the diagnosis.

FIGURE 36-3. (A) Illustration of atrophic vaginitis versus normal mucosa. Signs of atrophic vaginitis may include pale, smooth, shiny mucosa with patches of inflammation and petechiae.

(B) Illustration of remodeling of vaginal mucosa in response to topical estrogen therapy. (B, Reproduced with permission from Reiter S. Barriers to effective treatment of vaginal atrophy with local estrogen therapy. Int J Gen Med. 2013;6:153–158.)

Low-dose topical estrogen remains the preferred treatment for atrophic vaginitis in most women. It is the most proven for symptom relief, and there are several delivery options, via ring, tablet, capsule, or cream. Examples of low- and moderate-dose vaginal estrogen therapies are listed in Table 36-3. The ring can remain in the vagina for 3 months, releasing 6 to 9 µg of estradiol daily. Tablets containing 10 µg of estradiol may be inserted nightly for 2 weeks, then twice a week indefinitely. Daily use is required initially to stimulate mucosal remodeling, because the very low maintenance dose alone is not sufficient. The dose and absorption of both the ring and the tablet are specific and well-studied. Serum estradiol rises briefly in the first 24 hours then remains within the postmenopausal range.

TABLE 36-3 ¦ CHARACTERISTICS OF LOCAL VAGINAL HORMONAL TREATMENTS

Exact low dosage is difficult to achieve with creams, but cream has other advantages. The vehicle soothes the mucosa. Creams are often the least costly approach. The amounts needed to treat atrophic vaginitis are smaller

than the lowest measurements on the applicator; using an estimated 1/4 to 1/2 g twice weekly is reasonable. Some women find fingertip application of a pea- or chocolate chip–size amount placed into the vagina easier than inserting an applicator.

The lower urinary tract is also estrogen sensitive, as estrogen receptors are found in the bladder and urethra. The symptoms of dysuria, urethral discomfort, overactive bladder (OAB, consisting of urinary urgency, frequency, urgency urinary incontinence, nocturia), hematuria, UTIs, and UI are associated with aging. Estrogen has been a mainstay of treatment in urinary tract symptoms. There is a role for transvaginal estrogen in preventing recurrent UTIs.

Vaginal estrogen use in breast cancer survivors is controversial and best prescribed in consultation with an oncologist. Oral estrogen is contraindicated during breast cancer treatment, but no harm has been detected from use of low-dose intravaginal preparations with a history of breast cancer. Patients taking aromatase inhibitors may achieve undesirably high premenopausal serum estrogen levels, warranting extra precaution or consultation before and during any estrogen treatment. Concerns seem to only apply to hormone-sensitive cancers as no increased recurrence of hormone receptor–negative cancers has been found with any type of postmenopausal hormone therapy. Nonetheless, women with a history of breast cancer should try nonhormonal treatments first.

With these low doses, progestins to prevent endometrial hyperplasia or endometrial surveillance are not required. However, estrogen absorption varies considerably among individuals, and endometrial growth could possibly be stimulated. Any brown or red discharge necessitates evaluation of the endometrium as would be performed with any postmenopausal bleeding. Ospemifene is an oral estrogen agonist/antagonist, or selective estrogen receptor modulator (SERM), approved by the FDA for dyspareunia due to vaginal atrophy. It is effective for vulvovaginal atrophy and appears to have favorable effects on bone, neutral effects on the endometrium and the cardiovascular system, and no clinically significant estrogenic effect on the breast. Risks and contraindications are like those for estrogen, including venous thromboembolism. Vasomotor symptoms are bothersome in 10% of patients.

Other non-estrogen therapies are less reliable in reducing dyspareunia and irritative voiding symptoms, but often relieve mild symptoms. Vaginal

moisturizers are used on a regular basis, daily to weekly, to maintain epithelial moisture and vaginal pH. In addition, vaginal lubricants may be used for intercourse. Frequent sexual activity helps maintain supple tissues. Alternative hormonal agents (dehydroepiandrosterone, other SERMs, testosterone) are promising but not yet sufficiently studied.

Vaginal cancer accounts for 1% or less of female genital tract cancers. Metastatic disease of the vagina is more common than primary vaginal cancer, notably from cancers of the endometrium, cervix, vulva, ovary, breast, rectum, and kidney. The most common primary vaginal cancer is SCC, but adenocarcinoma, sarcoma, melanoma, and others occur. Vaginal SCC is often preceded by vaginal intraepithelial neoplasia, which is associated with concomitant cervical or vulvar neoplasia in about 50% of cases. It is usually asymptomatic and not easily visible, but induration may be palpable. Two-thirds of cases occur in the upper vagina. Risk factors for primary vaginal cancer are the same as those for cervical cancer, including prior gynecologic cancer and radiation therapy. Bleeding, discharge, pain, and urinary or rectal complaints are presenting symptoms. Survival drops precipitously beyond stage II.

The location of the squamocolumnar junction, the border between squamous (ectocervical) and mucous (endocervical) epithelia, changes location over a lifespan. It is usually within the endocervical canal in older women and not visible. Its importance lies in the fact that it is the most common site of cervical neoplasia. Cystic structures near this border are almost invariably Nabothian cysts. These are not true cysts, but collections of mucus trapped during metaplastic transition, when squamous cells cover mucus-secreting crypts. They do not require biopsy. Any lesion whose benignity is uncertain should be biopsied or referred. Cytology is a screening test and alone is not an appropriate evaluation of a visible lesion.

Worldwide, cervical cancer is the most common gynecologic cancer and the fourth most common cancer overall in women. Most incident cases and 87%

of cervical cancer-related deaths occur in less-developed countries due to the lack of access to appropriate screening and treatment of preinvasive disease. In the United States, there are an estimated 12,820 cervical cancer diagnoses and 4210 deaths annually. The risk of cervical cancer increases with age, and the case-fatality rate is higher in older women. While women over age 65 years represent approximately 14% of the US female population, more than 20% of new cervical cancer cases and a disproportionate amount of cervical cancer deaths are in this age group. Most of these are in unscreened or inadequately screened women. Three-fourths of cervical cancers are SCC; the remaining adeno-, adenosquamous, and clear cell carcinomas have higher mortality rates. In older women only half to two- thirds of cervical cancers are associated with HPV. Postcoital bleeding may occur at an early stage, but other symptoms (pain and bowel or bladder symptoms) are absent. Radical hysterectomy is the primary treatment for early-stage cervical cancer. Radiation therapy is used for locally advanced disease, as adjunctive treatment, when surgery is not an option, and along with chemotherapy for palliation.

TABLE 36-4 ¦ CRITERIA (ALL OF WHICH SHOULD BE MET PRIOR TO DISCONTINUING CERVICAL CANCER SCREENING)

The excess deaths from this mostly preventable malignancy are only avoided through screening, including “adequate” screening of older women.

Screening older women provides equivalent benefit to screening younger women, that is, an equivalent reduction in severe cervical intraepithelial neoplasia (CIN) and, by inference, of cancer. However, due to low cancer incidence and long lead time, routine screening after age 65 provides little benefit if women have been adequately screened prior to this. The key to safe discontinuation is knowing the patient’s screening and risk factor history. The three main issues in older women are (1) when to discontinue screening,

(2) in whom to continue screening, and until what point, and (3) the best screening modalities.

The ACOG, American Society for Colposcopy and Cervical Pathology (ASCCP), the United States Preventive Services Task Force (USPSTF), the American Cancer Society (ACS), and other organizations recommend discontinuing cervical screening after appropriate criteria are met. The criteria include that the patient should be age 65 or older, low risk, and have had adequate negative screening. Adequate is defined as three consecutive negative cervical cytology tests or two negative cytologic tests with negative HPV co-testing in the past 10 years, the most recent of which was within the past 5 years. Ideally the final test would include HPV genotyping. Women older than 65 should continue with screening until these criteria are met.

Screening should continue for at least 25 years after documented regression or treatment of a precancerous lesion, even if this extends after age 65.

Having a new sexual partner after age 65 does not necessitate additional screening.

Screening of women who have undergone a total hysterectomy (corpus et cervix uteri) is not recommended unless the hysterectomy was performed for dysplasia, for cancer or the woman is a DES daughter. The positive

predictive value of vaginal cuff cytology after hysterectomy for benign disease is approximately zero. Many women do not know whether their hysterectomy was total or supracervical (corpus alone). This can be determined at the initial pelvic examination. If a cervix is unexpectedly discovered, adequate screening should be performed before discontinuation.

Risk factors for cervical cancer include an abnormal Pap smear within the past decade, a history of moderate or severe CIN (CIN 2 or 3) within the past 25 years; a history of cervical, vaginal, or vulvar cancer; immune suppression; and DES exposure in utero. These groups are excluded from major society guidelines for lengthening screening intervals and discontinuation, but without sufficient alternative recommendations. As mentioned earlier, screening should continue for at least 25 years following successful treatment for CIN 2+. Women infected with human immunodeficiency virus (HIV) should continue annual screening indefinitely. Other causes of immune suppression including solid organ transplant, autoimmune disorders, treatment with glucocorticoids, and chronic antineoplastic therapies are not addressed. The relevance of DES exposure in utero to cervical or vaginal cancer risk in advanced age is uncertain.

Although ACOG recommends continuing annual internal pelvic examinations indefinitely in DES daughters, it does not specifically address cervical or vaginal cytology.

Both the uterus and leiomyomata (fibroids) typically decrease in size after menopause. Therefore, a palpably large uterus (navel orange or grapefruit sized) is unusual. Previous medical records would probably clarify whether this is a new finding. If unclear, sonographic evaluation would inform the need for further evaluation or referral to a gynecologic specialist. Uterine tenderness is also unusual. Bacterial endometritis is uncommon, but can occur even in the absence of uterine manipulation. It is usually associated with a purulent, odorous discharge and/or bleeding.

Endometrial cancer is the most common gynecologic malignancy in developed countries and the second most common in developing countries. The mortality rate has been declining slowly, but more than 10,000 women

still die annually in the United States of this disease. An estimated 61,380 new cases of uterine cancer are diagnosed annually in the United States, and 10,920 women die per year because of this disease. Patients 65 and older account for 44.3% of new endometrial cancer diagnoses and 66.6% of endometrial cancer deaths. Incidence rates in Europe and North America have risen since the 1980s, possibly related to increases in obesity and life expectancy with a concomitant decrease in birth rates. Ninety percent of uterine cancers originate in the endometrium. Three-fourths are type I endometrioid adenocarcinoma. Type II is more aggressive and characterized by clear cell and papillary serous tumor histology. Papillary serous carcinoma accounts for only 10% of uterine cancers but 40% of uterine cancer deaths.

Type I endometrial cancer is associated with traditional risk factors related to estrogen abundance and inadequate progestin. It tends to present at an earlier stage and younger age than does type II. Risk factors include early menarche and late menopause, obesity, chronic anovulation, type 2 diabetes, hypertension, and nulliparity. Pregnancy, lactation, hormonal contraceptives (including a progesterone-releasing intrauterine device), and postmenopausal hormone therapy with continuous (not intermittent) progestins are protective historical factors. Pathogenesis and risk factors for type II endometrial cancer are less well understood. Although the effect size of risk and protective factors is stronger in most studies for type I cancer than for type II, the factors are surprisingly similar. Risk factors include body mass index, early menarche, and diabetes; protective factors are higher parity, oral contraceptive use, and cigarette smoking.

Endometrial cancer is the most common sentinel cancer in Lynch syndrome, an autosomal dominant condition caused by germline mutations in mismatch repair genes. Lynch syndrome accounts for 2% to 5% of endometrial cancers and is more associated with younger age and type I histomorphology. The question of universal versus selective genetic screening in endometrial cancer patients remains to be resolved. The 2014 Clinical Practice Statement from the Society for Gynecologic Oncology (SGO) recommends that “all women who are diagnosed with endometrial cancer should undergo systematic clinical screening for Lynch syndrome (review of personal and family history) and/or molecular screening.

Molecular screening of endometrial cancers for Lynch syndrome is the preferred strategy when resources are available.”

A hysterectomy with bilateral salpingo-oophorectomy, lymph node sampling, and tumor debulking is required for endometrial cancer staging and is the mainstay of treatment. Radiation and/or chemotherapy may be used adjunctively or in women who are too frail to undergo surgery. Overall, 5- year survival is estimated at 82% since bleeding usually leads to early diagnosis and treatment. Older age is associated with a worse prognosis because more aggressive tumors are relatively more common, as well as due to comorbidity, late diagnosis, and lack of aggressive treatment.

Malignant lesions of the myometrium include leiomyosarcoma and other sarcomatoid tumors. These are less likely to cause bleeding in early stages, and may only be detected by the presence of an enlarging uterus or pelvic mass, or be discovered after hysterectomy. Incidence of leiomyosarcoma peaks in the sixth and seventh decades. They are aggressive tumors with high metastatic potential. Treatment involves surgery, chemotherapy, and radiation. Extension of tumor beyond the confines of the uterus is associated with a poor prognosis.

Abnormal vaginal bleeding occurs in up to 20% of postmenopausal women, 10% to 20% of the time due to endometrial hyperplasia or neoplasia. Studies invariably analyze “postmenopausal” as one group, so these statistics misrepresent the risks in older women. Older women bleed less often, but older age increases the risk of malignancy and of a higher-grade cancer.

Although most women with postmenopausal bleeding will be referred to a gynecologist, a focused history and examination will ensure the best referral. A rectal polyp, urethral mucosal prolapse, vulvovaginal pathology, or neglected pessary may be discovered.

All pelvic bleeding sources should be investigated, including hematuria, hematochezia, vulvovaginal pathology, and trauma (Table 36-5). The external genitalia, vagina, and cervix are inspected for ulcerations, atrophy, abrasions, polyps, etc. If the cervix appears normal, screening with both cytology and HPV genotyping (co-testing) is advisable unless recently performed. An abnormal appearing cervix warrants biopsy. Bimanual and rectal examinations will help rule out pelvic masses, tissue induration, and rectal pathology.

Regardless of other findings, the endometrium must be evaluated with a biopsy or transvaginal ultrasound in the setting of postmenopausal bleeding. Office biopsy can have greater than 99% sensitivity, but not all devices achieve this. ACOG states that endometrial sampling may be deferred if the endometrial thickness is 4 mm or less. However, biopsy for tissue diagnosis is preferable to sonography to evaluate the endometrium in older women or in those with recurrent or persistent bleeding regardless of imaging.

No guidelines have been established for the evaluation of vaginal bleeding in frail, impaired older women. Even if aggressive treatments are not an option, palliative management improves when the disease process is understood. Evaluation of vaginal bleeding including biopsy can always be recommended, guided by clinical judgement and the patient’s wishes.

“Adnexa” is a plural word meaning “parts.” Adnexa uteri refers to the fallopian tube and ovary. Adnexal masses can be, accordingly, of either the tube or ovary, but many other gynecologic and non-gynecologic pathologies masquerade as adnexal masses. Definitive diagnosis of an ovarian mass generally requires excisional surgery. However, imaging can obviate surgery in most patients. Although the chance of malignancy is increased after menopause, most adnexal masses are benign.

Menopause occurs when the ovary ceases its cyclic reproductive function and shrinks to an average volume of less than 4 cm3. It continues to be an important source of androgen production, but not of estrogen. Functional cysts, normally associated with development of mature ova, still occur often after menopause. These generally resolve without intervention. Benign

lesions are overwhelmingly epithelial tumors, usually cystadenomas. Tumors may also arise from stromal or germ cells, but most of these occur at younger ages. An endometrioma may persist indefinitely and is unlikely to grow or become newly symptomatic in older women.

Transvaginal ultrasound is the preferred imaging study for adnexal masses. Magnetic resonance imaging (MRI) is best suited to clarify the malignant potential if ultrasound is unreliable or cannot be performed transvaginally. When extraovarian disease is suspected or needs to be ruled out, computed tomography (CT) scan is the most reliable technique.

Ultrasonography may be useful even when the adnexal mass was discovered on another imaging study, sometimes adding information that better characterizes the ovaries and uterus. For cysts that will be followed, it is best to measure size over time with the same imaging modality, and ultrasound is less expensive.

Simple cysts less than 10-cm diameter will resolve spontaneously in half of older patients, indicating they were functional cysts. Most of the persistent ones eventually excised are benign epithelial tumors. Complex ovarian masses, with loculations or solid components, comprise 3% of postmenopausal adnexal masses. These are more concerning for neoplasia, but up to half may also resolve spontaneously. If an asymptomatic simple cyst is smaller than 10-cm diameter on transvaginal ultrasound and the serum CA- 125 is not elevated, the usual plan is to repeat these studies in 3 to 6 months. Indications for urgent gynecologic consultation include size greater than or equal to 10 cm, complex components, or an elevated CA-125.

Ovarian cancer is the deadliest of the gynecologic cancers and is the fifth leading cause of cancer death in women in the United States. Approximately 1 in 70 women will be diagnosed with ovarian cancer in their lifetime. In 2020, an estimated 21,750 women were diagnosed with ovarian cancer in the United States, and 13,940 died from this disease. The median age at diagnosis is 63. The age-specific incidence peaks at age 80 to 84, and subsequently plateaus. Survival rates are poor primarily because of diagnosis at advanced stage. Initial symptoms are nonspecific, such as abdominal or pelvic pain, bloating, urinary complaints, and constipation. It is now appreciated that early-stage cancers are often symptomatic. In retrospect, most ovarian cancer patients have had symptoms for several

months prior to diagnosis. While a transvaginal ultrasound and CA-125 blood test perform poorly as screening tests in low-risk women, they are useful to rule out ovarian cancer when abdominal, pelvic, gastrointestinal, or urinary symptoms are present. Early evaluation of symptoms has not been proven to improve survival, but some evidence suggests it identifies more women with completely resectable disease. Genetic testing is evolving rapidly. It is now thought that approximately 25% of ovarian cancers have a germline mutation.

Most ovarian malignancies in older women are epithelial. The paradigm of epithelial ovarian cancer pathogenesis has undergone radical changes in the past decade. Rather than arising from the ovarian cortex, most cancers are likely derived from the fallopian tube or the endometrium. Epithelial ovarian cancers are now divided into two broad categories. The relatively indolent type I tumors are comprised of low-grade serous, low-grade endometrioid, clear cell, and mucinous carcinomas, and Brenner tumors. Type II tumors are high-grade serous, high-grade endometrioid, and other aggressive carcinomas. While these new distinctions have few direct implications for geriatrics practice, they have expanded preventive surgical strategies. ACOG recommends performing incidental bilateral salpingectomy whenever possible. Older women already routinely undergo bilateral salpingo- oophorectomy incidental to abdominal hysterectomy, but not routinely during vaginal surgery. This should be considered in preoperative planning, but there are inadequate data to fully inform this decision.

Surgery is indicated for most women with ovarian cancer, even in advanced age, both for staging and improved survival with optimal tumor debulking. Treatment outcomes are better on average when the initial surgery is performed by a gynecologic oncologist rather than a general gynecologist, due to more complete staging and debulking. Having one surgery for diagnosis and partial treatment, then a subsequent one to finish the staging and treatment is associated with worse outcomes. This may have implications for referrals from a geriatrics practice.

Menopause is defined as 12 months of amenorrhea secondary to cessation of ovulation. This can also be attained by surgical oophorectomy,

chemotherapy, or radiation. The transition to menopause referred to as the perimenopause begins approximately 4 years prior to the last menstrual period and starts with irregular cycles during which time estrogen levels can be normal or elevated. Progesterone and estradiol levels decrease with an increase in follicle-stimulating hormone (FSH) levels. The postmenopausal estradiol levels are usually less than 20 pg/mL, while FSH is most often more than 70 mU/mL. Symptoms attributed to menopause include vasomotor (hot flushes and night sweats), vaginal atrophy (pruritis, dryness, and dyspareunia), UI, sleeping difficulty, depression, anxiety, mood changes, cognitive decline, and somatic complaints. Migraine prevalence may also increase in perimenopausal women due to estrogen fluctuations. Therefore, consideration of hormone therapy and the alternatives is important for symptom management and quality of life.

Estrogen and estrogen plus progestin hormone therapy (HT) following menopause has a complex constellation of statistically small benefits and risks, and symptoms can often be managed with nonhormonal alternatives. Estrogen therapy is by far the most effective treatment for vasomotor symptoms of menopause. However, the use of systemic estrogen has been complicated by the results of the Women’s Health Initiative (WHI), which found that the use of systemic estrogen alone increased the risk of stroke (relative risk 1.39), while the addition of progestin increased the risk of coronary events (relative risk 1.28), breast cancer (relative risk 1.26), and pulmonary embolism (relative risk 2.13). The absolute risk of these events is much lower in younger premenopausal women.

While initiation of HT after age 65 is contraindicated, continuation of HT taken since menopause should be decided on an individualized basis. The ACOG and the North American Menopause Society (NAMS) recommend that the lowest effective dose of systemic estrogen (plus progestin if uterus is present) should be used and estrogen replacement not be used for disease prevention. The marginal risk of continuation is very small. However, given the association with stroke and cardiovascular events, most women over age 65 will choose to discontinue HT. The issue then becomes how to discontinue without suffering excessive menopausal symptoms.

Four randomized trials studying fewer than 300 women have evaluated abrupt discontinuation versus tapering over 2 weeks, 4 weeks, 4 months, and

6 months. Overall successful discontinuation rates were similar, but symptoms were generally greater in the abrupt discontinuation groups. Roughly half of women tolerate sudden cessation but do better with ongoing clinical support for up to 3 years. Others experience unacceptable vasomotor symptoms, insomnia, irritability, short-term memory loss, or fatigue and resume HT. Anecdotally, tapering over an even longer time would yield greater success with fewer symptoms. Unless urgent, this can be done as slowly as necessary, reducing the dose every few months or annually. When the lowest commercially available dose has been reached, the taper can be continued dropping one weekly dose at a time once a month or as tolerated.

Vasomotor symptoms can also be ameliorated with nonhormonal medications. Paroxetine, clonidine, and gabapentin have all shown efficacy in symptom management; however, paroxetine is the only nonhormonal agent with FDA approval for this indication. These may be trialed as initial therapy or as management after discontinuation of hormonal therapy. Each of these drugs have significant side effects in the older population.

Occasionally an older woman not taking estrogen experiences new-onset vasomotor symptoms. Pertinent history includes onset, frequency, duration, timing during the day or night, facial erythema, perspiration, flushed feelings, associated activities, and her symptoms at the time of menopause.

Medications or supplements are often implicated in new symptoms; however, other etiologies should be evaluated including thyroid function. While hormone-related vasomotor symptoms do not suddenly arise years after a decline in estrogen, it is unclear in some cases whether hormones could be involved. A trial of estrogen therapy for 1 to 3 months can be informative or educational. Transdermal administration would minimize the risk of a vascular event as this avoids first-pass metabolism in the liver.

POP, UI, and UTI are very common gynecologic problems experienced by older women. Incontinence and infection are covered in more detail elsewhere. This section will focus on several specific conditions common in urogynecology and female urology including POP as well as bladder and urethral disorders such as IC, urethral caruncle, urethral cancer, urethral

stricture, and urethral diverticulum. Urinary incontinence is discussed in Chapter 47.

Several disorders of the female urethra occur with greater incidence and prevalence in older women compared to their younger counterparts. A urethral caruncle generally appears as a polypoid red mass protruding from the urethra at the 6 o’clock position. This is often asymptomatic and identified incidentally on physical examination (see Figure 36-2). Some patients may notice it and are often concerned for possible malignancy.

Urethral caruncles are typically soft to palpation, although they may bleed due to irritation. They represent an incomplete prolapse of the urethral mucosa with possible loss of support of the periurethral muscular-connective tissue. Topical estrogen is generally effective and may lead to reduction in size or complete involution of the caruncle.

Urethral prolapse, in contrast to caruncles, is complete circumferential mucosal prolapse. It is managed similarly to a caruncle and, in most cases, resolves with topical estrogen. If there is persistent pain, bleeding, or other concerns, referral is warranted for further evaluation and consideration of surgical management.

In contrast, urethral cancers in women may present with bleeding and are typically hard or firm to palpation. The tumor can extend proximally toward the bladder neck, or into the vagina. Treatment is typically surgical, although radiation may also be used in select cases or for palliation.

Urethral strictures in women are uncommon. Surgical excision and reconstruction are the most effective form of therapy. Urethral dilation should be avoided in women and is not particularly effective for long-term therapy. There are no data to support routine urethral dilation for treatment of UTI or voiding dysfunction in most women.

Urethral diverticulum results from an outpouching of tissue in the urethra associated with a defect in the midline fusion of the urethral plate. Women often experience the “3-Ds” of dysuria, dyspareunia, and dribbling incontinence; they may also be associated with recurrent UTIs. Differential diagnosis for urethral diverticulum includes vaginal wall cysts from an embryologic remnant (Gartner’s duct cyst) or local gland (Skene’s duct cyst) and ectopic ureterocele. Surgical excision with urethral closure or reconstruction is typically indicated. Urethral malignancy has been found in

approximately 6% to 9% of patients with a urethral diverticulum; the most common type of malignancy is adenocarcinoma. Magnetic resonance imaging is the imaging modality of choice prior to surgical management.

Interstitial cystitis (IC), also called painful bladder syndrome (PBS), is a chronic condition of the bladder typically associated with a constellation of symptoms including urinary urgency, frequency, and pelvic pain. It is generally diagnosed in women in their 30s or 40s but must be chronically managed throughout a woman’s lifetime as there is no cure. Patients generally experience worse pain with bladder filling, which is relieved at least temporarily by voiding. Pain is a hallmark symptom and helps to differentiate the condition from overactive bladder (OAB) and other forms of lower urinary tract dysfunction. The exact etiology of IC is unknown although theories include autoimmune components, direct chemical irritants in the urine, effects from inflammatory mediators, and defects in the bladder epithelial barrier layer. Other conditions that should be ruled out in cases of possible IC include bladder cancer, bladder carcinoma in situ, UTI, and bladder stones. Continued symptoms in the context of persistent negative urine cultures should prompt the clinician to consider IC.

Diagnosis can be made based on clinical symptoms and ruling out other etiologies. Cystoscopy with hydrodistension of the bladder under anesthesia is a useful diagnostic tool and may also be therapeutic for many patients.

Reduced bladder capacity and mucosal changes including petechial hemorrhage are commonly seen in cases of IC. Ulcerations of the bladder mucosa occur less commonly but may represent more severe disease.

Cystoscopy also offers the clinician the opportunity to visually examine the bladder to rule out other serious conditions such as bladder cancer, particularly in older women where the rates of bladder cancer increase compared to young women. Bladder wash cytology and biopsies may also be used to help aid in the diagnosis of bladder cancer. Patients may be treated for IC or PBS without cystoscopic confirmation of the condition, but in older patients it is wise to eliminate other potential pathologies. Referral to Urology is indicated if a patient has persistent or progressive symptoms not adequately managed with conservative therapy.

POP can be quite bothersome for older women. Incidence and prevalence rates of POP increase with advancing age. Risk factors include prior hysterectomy, obesity, smoking, parity, poor tissue quality, and connective tissue disease. Several different types of prolapse occur depending on the involved anatomy. Patients may experience a bulging sensation from the vagina or may complain of pressure or discomfort in the pelvis or lower back. Bleeding and discharge are common symptoms, particularly in women with large prolapse extending out of the vaginal canal, and may be associated with erosion, ulceration, or keratinization of the exposed vaginal mucosa.

Clinical evaluation includes careful history and physical examination (Table 36-6). Symptoms should be identified to help gauge the degree of bother experienced by the patient, which in turn can help determine the types of treatment that can be considered. In patients with little symptomatic bother and minimal other signs or symptoms, observation may be adequate. Careful pelvic examination is critical in making the correct diagnosis of POP. Prolapse of the anterior vaginal wall is a cystocele, and the posterior vaginal wall is typically a rectocele. Loss of support of the vaginal apex may include small bowel which is known as an enterocele. Uterine prolapse may also occur due to loss of support of the cardinal or uterosacral ligaments.

Complete vaginal eversion may occur in women with a prior hysterectomy, or “procidentia” if the uterus is in situ.

TABLE 36-6 ¦ EVALUATION AND MANAGEMENT OF PELVIC ORGAN PROLAPSE

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??t rior vagjnal wall. p t rior agi11al wall. aginaJ ape r ix 11d ut ru - upp rt and m bility

B rri 1· c1· am 1· intm 11t t p1· t ct aginal muc a Tru - trong lastic uppo1·t

Physical examination is important for complete assessment. On simple inspection, it can be difficult to differentiate the portion of the vagina involved in the prolapse. A single-blade speculum is useful for this purpose. The speculum is initially inserted to depress the posterior vaginal wall. The speculum is then reinserted in the reverse position to elevate the anterior vaginal wall allowing inspection of the posterior compartment for evidence of rectocele. Asking the patient to cough and Valsalva can help to demonstrate prolapse that may increase with abdominal straining. It can be useful to also examine the patient in the standing position if possible, as some prolapse may only be evident with standing.

A cystocele occurs because of a weakness of the anterior vaginal wall muscular-connective tissue. The bladder protrudes into the vaginal space, and in some cases may extend beyond the hymenal ring. Cystoceles may or may not be associated with stress UI. Some women with large cystoceles may have trouble voiding due to obstructive angulation of the urethra or poor bladder contractility (Figure 36-4). In some cases, women with large cystoceles may report having to put their fingers in the vagina to elevate the tissue to straighten out the urethra to urinate or to completely empty the bladder. Despite this, high-grade obstruction in women is rare, and development of upper tract deterioration with hydronephrosis and renal insufficiency is uncommon. Hydroureter and hydronephrosis can occur if there is substantial ureteral kinking at its insertion into the bladder in cases of complete vaginal vault prolapse. This is more likely if the uterus is present.

Serum blood urea nitrogen and creatinine level and renal ultrasound are useful in determining the extent of renal impairment.

FIGURE 36-4. Anterior and sagittal views of a cystocele. Note the increasing size of a cystocele (A) and that it can cause angulation of the urethra and contribute to symptoms of voiding difficulty and urinary retention (B).

A rectocele is a protrusion of the rectum through the posterior wall of the vagina and is caused by weakness in the perirectal muscular-connective tissue (Figure 36-5). Some patients may describe difficulty with defecation, including an increased sense of pressure or need to strain. Some women describe needing to “splint” or press on the posterior vaginal wall or perineum to completely evacuate their stool.

An enterocele is a herniation of small bowel and peritoneum through the apical vagina or between the uterosacral ligaments and rectovaginal space (Figure 36-6). It is the only true hernia among the various forms of POP. It is more common in women who have undergone prior hysterectomy. However, it can be present in any posterior vaginal wall prolapse, and rarely in anterior compartment prolapse.

Rectal prolapse involves protrusion of the rectum through the anal sphincter with tissue extending beyond the anal verge. It may or may not be associated with hemorrhoids. Symptoms of rectal prolapse can include pain,

bleeding, or defecatory dysfunction. Many patients experience both fecal incontinence and constipation. Careful examination is needed to determine if the rectal prolapse can be reduced. In cases where reduction is not possible, tissue incarceration and necrosis may develop. Patients with rectal prolapse should be referred to a colorectal surgeon or gastroenterologist for additional evaluation and treatment.

Several different systems have been designed to grade the degree of POP based on anatomic changes. The Baden-Walker system was commonly used in clinical practice, and classifies the degree of prolapse based on whether it extends beyond the midpoint of the vagina or beyond the vaginal introitus, when it is more likely to become symptomatic. The POP-Q system is more commonly used in research settings but is also useful in a simplified approach in defining the leading edge of the prolapse. It includes multiple anatomic measurements in relation to the vaginal introitus. In most systems, the hymenal ring is used to define the vaginal introitus. A clear understanding and documentation of the extent of prolapse is useful for surgical planning and for following progress over time (Figure 36-7).

FIGURE 36-7. Treatment of pelvic organ prolapse. (Reproduced with permission from Bump RC, Mattiasson A, Bø K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol. 1996;175[1]:10–17.)

Most treatments are aimed at reducing the prolapse back into the vaginal canal and correcting vaginal anatomy (see Table 36-6). Ulcerations of the

vaginal epithelium may respond to topical estrogen therapy. Barrier compounds may also be helpful to reduce tissue irritation.

Treatment of POP may be surgical or nonsurgical and depends to some degree on the amount of bother experienced by the patient. It also depends on overall health status, and goals of therapy. The main conditions necessitating definitive treatment or specialist referral include nonhealing ulcerations, bleeding, elevated postvoid residual urine volume causing recurrent UTIs, and hydronephrosis. If none of these are present and the patient is not particularly bothered by her symptoms, then reassurance and observation are appropriate. Application of estrogen cream once or twice a week is advisable for preventive care and can help reduce tissue irritation and ulceration. Some patients may find comfort in using supportive underwear.

Nonsurgical treatment of POP and UI includes such treatment as behavioral therapy (pelvic floor muscle exercises including stress and urgency incontinence strategies), medications, as well as the use of intravaginal support devices. One should consider first starting with a conservative treatment approach in older women who do not have a desire for surgical intervention or in cases where surgical intervention may not be an ideal choice due to the medical comorbidities causing the increased surgical risk.

With respect to pelvic floor muscle exercises, they may limit the progression of mild prolapse and related symptoms, but less response has been noted with prolapse beyond the vaginal introitus. Pelvic floor muscle exercises are usually employed to treat accompanying urinary and/or fecal incontinence. Results are generally dependent on patient motivation and the patient’s willingness to comply with an exercise treatment program.

The use of a pessary has been considered an excellent option for nonsurgical management of POP and UI. Patient acceptance is relatively high when appropriately counseled. There are a number of different sizes and shapes for pessaries and most of them are made from silicone. The risk factors for a failed fitting include a large genital hiatus and a short vaginal length. Pessaries provide pelvic organ support within the vaginal vault.

There are two categories of pessaries for POP: support pessaries and space- filling pessaries. The ring pessary (with a diaphragm) is one of the most used support pessaries while the Gellhorn pessary is a commonly used space- filling pessary. Most women who have a stage II or stage III prolapse are

successfully fitted with ring pessaries while women with stage IV prolapse usually require a Gellhorn pessary.

Some of the possible complications from pessaries include odor and vaginal discharge. There may also be a failure to retain a pessary or the pessary may be too large, which could lead to excoriation or irritation. There may also be increased stress incontinence with reduction of the vaginal prolapse and in rare instances more severe complications such as fistula formation.

Ideal follow-up for pessaries should be tailored to the patient. Some patients can remove pessaries by themselves and clean them while other patients are less mobile and are cognitively impaired and may need very close follow up within 1 to 3 months. Each clinician should evaluate the tissue health of the patient, the cognitive and mobility status of the patient, type of pessary being utilized, and the patient’s home/living situation and then assess the patient for the appropriate treatment plan for each patient depending on the aforementioned factors. Assessing tissue health and the use of vaginal estrogen cream accompanying the pessary are important aspects of managing pessary care.

Surgical management of POP includes either reconstructive or obliterative procedures. Reconstructive options aim to reduce the prolapse and reestablish normal vaginal anatomy. Examples include anterior and posterior colporrhaphy and enterocele repair. Prolapse of the vaginal apex may require more advanced repair techniques including vaginal, abdominal, laparoscopic, or robotic approaches to the vaginal apex. For example, one can perform a vaginal uterosacral or sacrospinous ligament fixation, in which the apex of the vagina is sutured to a fixed point in the pelvis. In some cases, mesh or other supporting material is needed to perform this type of repair such as sacrocolpopexy. Potential complications include mesh erosion through the vaginal wall or other surrounding structures. Colpocleisis is an obliterative procedure in which the prolapse is reduced and the vagina is essentially closed to prevent recurrence. For a specialist, it is technically straightforward and may offer an option for older women with substantial comorbidity who may not be good candidates for more involved reconstructive procedures. However, patients need to be carefully counseled that penetrative sexual activity will not be possible after colpocleisis.

Studies have shown that in carefully selected patients, satisfaction rates are high with low rates of regret regarding the procedure. Rectal prolapse is typically treated surgically with either reduction, fixation, or excision of the prolapsed portion of the rectum. Treatments to prevent chronic constipation are indicated after all types of POP repair to avoid significant straining with bowel movements and prevent prolapse recurrence.

Although gynecologic issues comprise a small part of geriatric care, large impacts can be made on function and quality of life. A thorough personal and family history will guide cancer prevention and detection. An initial pelvic examination will provide the basis for understanding symptoms and anticipating problems, potentially for years to come. Querying problems in a systematic fashion addressing all potential gynecologic concerns will encourage the patient to voice symptoms when they arise. Persistence in addressing incontinence and pelvic floor issues can help maintain physical activity and prevent isolation. Ensuring adequate cervical cancer screening, early recognition of endometrial and vulvar cancer, and early investigation of abdominopelvic complaints to rule out ovarian cancer will reduce disease burden. Proactive assessment of pelvic floor conditions may also impact quality of life.

Karen L. Miller and Tomas L. Griebling contributed to this chapter in the 7th edition and some material from that chapter has been retained here.

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Sexuality is a basic human need that exists throughout life and is a significant component to quality of life of many older individuals. Although 70% of adult patients in a large sample study considered sexual matters to be an appropriate topic for a general clinician or geriatrician to discuss, sexual problems are noted in fewer than 2% of primary care physicians’ notes.

35. Sexuality, sexual function and dysfunction in the aging male, and the use of testosterone replacement therapy for male sexual dysfunction caused by male hypogonadism will be discussed in this chapter.

Numerous cross-sectional and longitudinal epidemiologic studies of sexuality and aging report that, although sexual activity decreases with age, many older adults are sexually active. Sexual expression can encompass many forms, but most studies report data on sexual intercourse, oral sex, and masturbation.

Figure 37-1A depicts the age-related prevalence of male sexual activity from two large studies. Both studies defined sexual activity as activity with a partner and occurring within the 12 months prior to the data collection. In these studies, the likelihood of sexual activity with a partner did decline with age, but nearly 40% of men at age 75 to 80 reported some sexual activity, and 54% of these reported sex at least two to three times a month.

FIGURE 37-1. A. Prevalence, by age group, of male sexual activity with a partner in previous 12 months obtained from a survey of a probability sample of 3000 US adults age 57 to 85 and from a population-based cohort study of 3274 men age 75 to 95. B. Prevalence of male sexual activity with a partner in previous 12 months, by age group, and of cognitive status as determined by short cognitive assessment tool, obtained from a survey of a probability sample of community-dwelling men aged 62 to 91. (A, blue bars, Data from Lindau ST, Schumm LP, Laumann EO, Levinson W, O’Muircheartaigh CA, Waite LJ. A study of sexuality and health among older adults in the United States. N Engl J Med. 2007;357[8]:762–774. A, red bars, Data from Hyde Z, Flicker L, Hankey GJ, et al. Prevalence of sexual activity and associated factors in men aged 75 to 95 years: a cohort study. Ann Intern Med. 2010;153[11]:693–702. B, Data from Lindau ST, Dale W, Feldmeth G, et al. Sexuality and cognitive status: a U.S. nationally representative study of home-dwelling older adults. J Am Geriatr Soc. 2018;66[10]:1902–1910.)

Reasons reported by older men for not engaging in sexual activity are varied, involving social factors as well as physical and psychological health. Partner availability (no partner, partner not interested, or partner with physical limitations) is a major factor. Psychological conditions, such as

anxiety and depression, can affect libido and sexual function; and many medical problems are linked to sexual dysfunction.

Overall there is a gradual slowing of sexual physical response time as men age. It takes more time to achieve sexual arousal, complete the sexual act, and become rearoused for further sexual activity. Table 37-1 lists the specific changes in the male sexual response cycle with age. Some of the changes have been shown to be impacted, at least in part, by low testosterone levels, while others are unaffected by hormone levels.

TABLE 37-1 ¦ CHANGES IN THE MALE SEXUAL RESPONSE CYCLE WITH AGE

Key Clinical Points

Male sexual activity declines with aging, due to social factors and changes in physical and psychological health; yet many older men are sexually active into late life.
The most common causes for ED in older men are vascular in origin, not hormonal, and thus current predominant therapies are phosphodiesterase-5 (PDE-5) inhibitors and vacuum devices.
Testosterone treatment improves libido, sexual activity, and erectile function in older men with hypogonadism (ie, men with symptoms and signs of testosterone deficiency and consistently low morning serum testosterone concentrations), but not in older men with normal testosterone concentrations.

As of 2017, somewhere between 1.4% and 2.4% of older men identified themselves as GBT. Older GBT men have similar sexual problems as older heterosexual men, but may suffer additional problems. GBT older men can face discrimination when seeking health care, and many service providers are poorly prepared to work with them. Additionally, these older men are likely to suffer additional stress while trying to find a partner, especially if their living situation changes and they move into assisted-living facilities or nursing homes. While assisted living and long-term care facilities have been evolving to become more welcoming to the LGBT community, disparities in care still exist. Specific organizations that address issues of aging gay, bisexual, or transgender persons have formed across the country.

Compared to younger gay men, however, older gay men get tested less often for sexually transmitted diseases, including testing for acquired immunodeficiency syndrome (AIDS). The incidence of AIDS is increasing in older men. Education about safe sex practices is important for the older population. Older males with a history of anal sex need to be regularly examined for anal cancer, as the prevalence increases in such persons.

Older GBT males should be encouraged to make advance directives for health and to specifically designate their durable power of attorney for health care in order to facilitate the ability of their partners to make their health decisions.

While there is no reason to believe the desire for intimacy is lost on entering a residential long-term care facility, persons who live in nursing homes frequently have no opportunity for a private or sexual life; many couples are separated due to the residential care admission. Federal regulations provide some right to privacy, and nursing home staff are becoming more educated about resident sexuality and issues that may arise as a result, but barriers to sexual expression in long-term care often are significant. Issues surrounding romantic liaisons between two unmarried residents in a nursing home can be problematic. Ethical concerns can arise around the assessment of sexual behaviors and whether they are “sexually inappropriate” or not, and may involve balancing a resident’s need for sexual expression against expectations and beliefs of caregivers and family members. If the sexual conduct involves one or both persons who are cognitively impaired, individual capacity to consent to sexual activity needs to be assessed. There is considerable variability by state in the definitions of capacity to consent to sexual activity and sexual consent is complicated, involving knowledge, capacity, and voluntariness. There are no surrogate decision makers for sexual relations. Psychological evaluation for capacity to consent to sexual activity may need to be sought. Also see Chapter 35, as similar challenges affect older women in these settings.

Development of cognitive impairment does not equate with loss of sexuality or sexual function. Although age-adjusted rates of partnered sexual activity are lower in those with worse cognitive function, the majority of community dwelling partnered older men with dementia are sexually active. In one study (Figure 37-1B), more than 40% of partnered men, ages 80 to 91 and who screened positive for dementia, were sexually active, although compared to the same age men with normal cognition, those men with dementia were more likely to report obligatory sex and sex without arousal. Issues of sexuality, however, can be especially complex for those individuals who have

significant dementia and can include loss of partner recognition, loss of memory of past sexual activity, and role changes, where one’s sexual partner now also is one’s caregiver. Physicians of demented male patients need to ask the spouse or partner about sexual issues or conflicts. Placing the problems in the context of dementia can assist with discussion of coping strategies. Nonsexual ways of expressing one’s intimacy, such as touching, holding hands, and massages, might be suggested.

Inappropriate sexual behavior (ISB) in individuals with dementia reportedly ranges from 7% to 25% with higher prevalence in men, in residents of nursing facilities, and in persons with more severe cognitive impairment. There is no universally accepted definition of ISB, but it has been described as sexually related activities or heightened sexual drive that interferes with function and is pursued at inappropriate times or with nonconsenting persons. Included in ISB are unwanted verbal remarks, unwanted touching, disrobing, public masturbation, unwanted sexual advances, and sexual aggression. ISB can cause conflict between a patient’s autonomy and the prevention of psychological and physical trauma. It impacts families, care providers, and, especially in long-term care facilities, may threaten others who might be unable or unwilling to give informed consent.

There are no established treatment protocols for ISB. Some environmental and behavioral strategies that have been tried include redirection, distraction, clothing modification, avoidance of external cues, and in long-term care facilities, provision of single rooms. Supportive psychotherapy for spouses and families can be helpful. There are no controlled trials of pharmacologic therapies for ISB, but medications that have been reported to reduce ISB include the selective serotonin reuptake inhibitors (SSRIs), venlafaxine, both first-generation and atypical antipsychotics, medroxyprogesterone acetate, gonadotropin-releasing hormone (GnRH) analogues, cyproterone acetate, cholinesterase inhibitors, pindolol, and gabapentin.

The major categories of sexual dysfunction in older men include erectile dysfunction (ED), lack of interest in sex (low libido), performance anxiety, and inability to climax. ED is by far the most prevalent. ED is defined as the

inability to obtain and sustain a penile erection adequate for intercourse. Age alone is a major risk factor for ED, and its incidence, prevalence, and severity increase with age. In the Massachusetts Male Aging Study, a community-based study of middle-aged and older men, the reported incidence of some degree of ED was 55% for men at age 60, and 65% for men at 70 years; the prevalence of total ED was 15% at age 70. In a population-based prospective cohort study in Olmsted County, Minnesota, ED prevalence was 6% in men aged 50 to 59, 17% in men aged 60 to 69, and

FIGURE 37-2. Prevalence, by age group, of erectile dysfunction (ED) from a longitudinal population-based study of community-dwelling men, and the 10-year follow-up incidence of cardiovascular events as a function of baseline presence or absence of ED. (Data from Inman BA, Sauver JL, Jacobson DJ, et al. A population-based, longitudinal study of erectile dysfunction and future coronary artery disease. Mayo Clin Proc. 2009;84[2]:108–113.)

Libido is dependent on learned responses, general health-related quality of life, and, to some extent, serum testosterone levels. As will be discussed later in this chapter, testosterone levels decline in men with normal aging, and some men may reach levels that are low enough to affect libido.

Similarly, treatment of prostate cancer with androgen deprivation therapy (ADT) resulting in severe testosterone deficiency can be associated with loss of libido.

Performance anxiety is common in older men and often a result of equating masculinity with speed and magnitude of sexual activity. A man may become so preoccupied by his performance that his confidence and sexual capacity lessen, leading to ED. Depression and psychosocial stresses also are prevalent in older men and contribute to sexual problems. “Widower’s syndrome,” where a man fails to achieve erection after the death of spouse, is a reported entity.

Inability to reach climax or resolution of climax without ejaculation can occur. In the University of Chicago study, this occurred in about 16% in the 57- to 64-year age range, but increased to 33% in the 75-year and older age group.

Etiologie s Table 37-2 lists the major etiologies of ED. Vascular disease, which includes both atherosclerotic arterial occlusive disease and corpora cavernosal venous leak, is the most common cause of ED. The likely mechanism is that penile hypoxia leads to replacement of corpora smooth muscle by connective tissue, which results in impaired cavernosal expandability and inability to compress subtunical venules.

TABLE 37-2 ¦ MAJOR ETIOLOGIES OF ERECTILE DYSFUNCTION

Cardiovascular disease (CVD) and ED share etiologies. Diabetes mellitus, hypertension, hyperlipidemia, and smoking are major risk factors for both ED and CVD. The penis is a high blood flow system during erectile function, so ED may be an early sign of vascular inadequacy on the basis of atherosclerosis. Numerous studies suggest that ED is one of the sentinel symptoms of occult CVD, particularly in men under the age of 70 (see Figure 37-2). It is recommended that men under the age of 70 presenting with ED should be provided appropriate screening and treatment for CVD.

Diabetes mellitus is the most common single disease to cause ED. Although the severity of hyperglycemia has been suggested as a predictor of ED, age, duration of diabetes, autonomic neuropathy, and other diabetic complications appear to be better predictors. Sometimes ED is the first symptom of diabetes mellitus, so all men who present with newly diagnosed ED should be evaluated for possible diabetes.

Neurologic diseases, such as peripheral neuropathy, spinal cord injury, stroke, multiple sclerosis, temporal lobe epilepsy, and Parkinson disease all can cause ED. In men who develop multiple sclerosis, about half of them present initially with ED. In these men, ED may be present for a time, then resolve and recur at the next exacerbation. Men with stroke-related ED also tend to have ejaculatory problems.

Significant other systemic diseases that can cause ED are renal failure and chronic obstructive pulmonary disease (COPD). Chronic renal failure impacts erectile function through effects on the vascular system and via the development of autonomic neuropathy. In addition, many men with end-stage renal disease are severely hypogonadal. Neither hemodialysis nor testosterone replacement in men with renal failure has been shown to improve ED. Men with COPD and low PaO2 have decreased cavernosal

nitric oxide. Oxygen therapy may improve erectile function in some men with COPD.

Hypercortisolemia and hyper- and hypothyroidism have been associated with low libido and ED. Hypothyroidism also is associated with delayed ejaculation, while hyperthyroidism is associated with premature ejaculation. Normalization of thyroid function frequently leads to improvement in both ED and ejaculatory dysfunction, although it may take up to 6 months after achievement of a euthyroid state for these functions to normalize.

Serum testosterone levels in men decline with aging, but the amount of contribution of this testosterone decline to the development of ED is not clear. In the Massachusetts Male Aging Study, where serum testosterone levels were measured throughout the study duration, 16% of the men who had no ED at baseline developed erectile problems within the next 8 years. Of the men who developed ED, 22% were in the lowest tertile for serum testosterone levels, but 12% were in the highest tertile. In the Concord Health and Ageing in Men study, where men 70 years and older were followed for 2 years, no association of ED and testosterone levels was found. Conversely, in the European Male Ageing Study, where men 40 to 79

were followed for over 4 years, becoming hypogonadal (as defined by serum total testosterone < 10.5 nmol/L) was significantly associated with development of ED. Unlike ED, a number of studies have reported that in healthy older men, libido does tend to correlate with serum testosterone levels.

ED and lower urinary tract symptoms (LUTS), occurring as the result of benign prostatic hyperplasia (BPH), frequently coassociate. A study in older men who had both ED and LUTS and were treated with the PDE-5 inhibitor, sildenafil, reported that both ED and LUTS symptoms improved with the sildenafil treatment.

While transurethral resection of the prostate (TURP) for BPH seldom results in ED, surgery for prostate cancer is more extensive and results in some degree of ED in about 60% of men. Nerve-sparing surgery offers a greater chance of preserving sexual potency. In addition, penile rehabilitation with PDE-5 inhibitors immediately following surgery helps prevent complete ED. ED also has been reported to be associated with pelvic radiation in up to 36% of cases. Peyronie disease, where fibrosis of the penile corpora cavernosa occurs, also can lead to erectile problems.

A number of lifestyle factors have been associated with the development of ED. Obesity alone is associated with a 20% increased risk of developing erectile problems. Weight loss may improve erectile function in obese patients. Smoking also can cause ED, both from direct effects of nicotine on penile smooth muscle and from longer-term effects on accelerating atherosclerosis. Heavy alcohol consumption (> 3 drinks/day) is associated with ED. Physical activity alone, regardless of weight, can improve or delay development of ED.

A large number of medications have produced adverse drug events reports involving male sexual dysfunction, usually ED. By and large, the effects on sexual function are medication class effects, based on mechanisms of action. The more common medications that have been reported to be associated with ED are beta blockers, diuretics, antiandrogens, opioids (chronic use), and antidepressents, particularly the SSRIs, venlafaxine, and the tricyclics. It is unlikely that medications would precipitate symptomatic ED in a man who had absolutely no erectile problems prior to initiating the medication, but for men with mild preexisting ED, these medications may precipitate clinically significant ED.

The first step in evaluation of sexual dysfunction is often the most difficult: eliciting the information. Asking a brief question about sexual activity in all patients can legitimize the topic for conversation. Examples of possible screening questions include: “Are you satisfied with your sexual activity?”; “How has your illness affected your sex life?” if the patient has a chronic illness; or “Many of my male patients your age have noticed some change in their sexual function; how about you?”

If sexual dysfunction is discovered during screening, then a more extensive sexual and health history and physical examination are warranted. A careful history from the man’s sexual partner also can be helpful. If psychological or couples’ problems exist, or if the patient is depressed, these should be treated. As noted earlier, an evaluation for general vascular disease and for diabetes, as well as a medication evaluation, should be done.

After addressing lifestyle modifications, medications and reversible causes of ED, the next step is consideration of direct medical treatments. Table 37-3 lists the current medical treatments for ED that are available in the United States.

TABLE 37-3 ¦ CURRENT MEDICAL TREATMENT OPTIONS FOR ERECTILE DYSFUNCTION AVAILABLE IN THE UNITED STATES

The most common first-line therapy of ED is an oral phosphodiesterase type 5 (PDE-5) inhibitor because of their efficacy (from 45% to 90%), ease of use, and generally favorable side effect profiles. The PDE-5 inhibitors available currently in the United States are sildenafil, vardenafil, tadalafil, and avanafil. Systemic reviews and pooled data across trials support that all four PDE-5 inhibitors have similar efficacy. Tadalafil has a longer duration of action and avanafil may have a more rapid onset of action compared to the others. Sildenafil and vardenafil must be taken on an empty stomach, as high- fat meals and/or alcohol delay their absorption, but food does not interfere significantly with the absorption of tadalafil or avanafil. They all require sexual stimulation to work effectively. Men with diabetes mellitus or after prostatectomy usually have more severe ED at baseline, so they often respond less well to PDE-5 inhibitors. Men who are hypogonadal may find PDE-5 inhibitors more effective if combined with testosterone therapy.

PDE-5 inhibitors have some vasodilatory activity and interact with nitrates. Therefore they are contraindicated in men taking nitrates. Men with LUTS/BPH who are taking a-adrenergic blockers, medications which also can lower blood pressure, should be cautioned when starting a PDE-5 inhibitor. Most common side effects of these agents are headaches, flushing, rhinitis, dyspepsia, myalgias, dizziness, back pain, and lowering of blood pressure. Sildenafil and vardenafil have some cross-reactivity with PDE-6, which may explain some reports of visual disturbances (usually a “blue haze”) with use of these medications.

Intracavernous injections with prostaglandin E1 (PGE1) or a PDE-5 inhibitor, with or without intracavernosal co-injection of an a-adrenergic blocker, have efficacy of 65% to 90%. Side effects include mild local pain (10%–15%), penile fibrosis, prolonged erections, and rhinitis. PGE1 (Alprostadil) also can be delivered via urethral insertion, followed by vigorous penile massage to assist with medication delivery. Reported efficacy is between 45% and 65% and side effects include mild pain, minor urethral bleeding, dizziness, and lowered blood pressure; there is a rare risk of anterior optic neuropathy.

Vacuum erection devices consist of a vacuum cylinder connected to a pump to create controlled negative pressure, and one or more constriction rings that go at the base of the penis after vacuum-induced engorgement has occurred. Intercourse occurs with rings in place, but the ring should not be left on for more than 30 minutes. Erection satisfactory for intercourse occurs in 75% to 90% of users. Overall satisfaction rate is 65% to 70% if the method is chosen and used, but only about 12% of men select the vacuum device as an initial choice of therapy. Side effects or reasons for dissatisfaction include pain, inconvenience, and premature loss of rigidity.

There are few contraindications to its use, but if on anticoagulants, these devices should be used with care.

Penile prosthetic implants are either semirigid (noninflatable) or inflatable. Designs have improved over the last decades, and the 5-year failure rates for the inflatable prosthesis are low. Infection is the most significant complication and varies from less than 1% to 16%.

Oral a-adrenergic blockers, such as yohimbine or phentolamine, have been used to treat ED, but with low efficacy (10%–20%) and are rarely used. Testosterone replacement therapy, with or without concomitant PDE-5

inhibitor treatment, has been used successfully to treat ED in some hypogonadal men (see following section).

Testosterone and its active metabolite, estradiol, play important roles in maintaining normal sexual function in men. Libido, sexual activity, and erectile function are reduced by severely low, castration-range, serum testosterone concentrations produced by ADT in older men with prostate cancer. In a recent study, healthy older men were treated with a gonadotropin-releasing hormone agonist (to induce experimental castration) and various dosages of testosterone (to produce very low to normal serum testosterone concentrations) for 16 weeks. In this study, sexual desire and erectile function were reduced slightly at serum testosterone concentrations less than 200 ng/dL; however, they were not reduced significantly relative to controls until serum testosterone levels were less than 100 ng/dL. These results suggest that the threshold of testosterone concentrations to maintain sexual function is relatively low and support results from previous observational studies.

Testosterone treatment is only indicated for men with hypogonadism (see Chapter 97). As per the Endocrine Society clinical practice guidelines, the diagnosis of hypogonadism requires clinical manifestations (ie, symptoms and signs) of testosterone deficiency and consistently low morning (preferably fasting) serum testosterone concentrations on at least two occasions. Sexual dysfunction symptoms (eg, low libido, loss of spontaneous erections, ED, and reduced sexual activity) are prominent manifestations of hypogonadism.

Meta-analyses have reported inconsistent effects of testosterone treatment on sexual function. Earlier meta-analyses utilized testosterone treatment trials in which men without symptoms or signs of testosterone deficiency or who had normal to low-normal testosterone levels were included. A more recent meta-analysis, however, included only the small number of randomized, placebo-controlled studies of 1779 men who had at least one symptom or sign of testosterone deficiency and morning testosterone concentration less than or equal to 300 ng/dL who received testosterone replacement therapy for more than or equal to 12 weeks. In this meta-analysis, compared to placebo, testosterone treatment of hypogonadal men was associated with a

modest but significant improvement in libido, erectile function, and sexual satisfaction.

The results of the Testosterone Trials (T Trials) are worth noting. This was a large, multi-center, double-blind, placebo-controlled study in older men (average age 72 years) with unequivocal hypogonadism (symptoms and signs of testosterone deficiency and two morning total testosterone levels by mass spectrometry < 275 ng/dL) for no apparent reason other than age. More details of the T Trials are provided in Chapter 97. Of the 459 men with low sexual desire (low libido) enrolled in the Sexual Function Trial of the T Trials, testosterone versus placebo treatment for 1 year resulted in moderate and sustained improvements in sexual activity, libido, and erectile function in older men with age-associated hypogonadism. The effect of testosterone therapy on ED as assessed by the International Index of Erectile Function (IIEF) was clinically meaningful, but less than that reported for PDE-5 inhibitors. In contrast to improvements in libido and sexual activity in testosterone-treated men that correlated with incremental changes in serum total or free testosterone and estradiol levels, the improvement in ED did not correlate with sex steroid concentrations. Also, no threshold testosterone concentration was apparent for any of the sexual function outcomes.

In contrast to men with hypogonadism, testosterone treatment does not improve libido, sexual activity or erectile function in men with normal testosterone (ie, eugonadal men). Also, in men with ED who fail to respond to PDE-5 inhibitors, the addition of testosterone treatment may improve erectile function as well as libido and sexual activity in men who have severe hypogonadism, but not in eugonadal men.

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